Mental Health final

Blood alcohol levels with a non tolerant drinker

"0.05 mg % - 1-2 drinks - changes in mood and behavior, impaired judgment 0.08 mg % - 5-6 drinks - legal level of intoxication in most states. Clumsiness in motor activity, poor judgment and self control 0.20 mg % - 10-12 drinks - depressed function of entire motor area of the brain causing staggering and ataxia; emotional lability, blackouts 0.30 mg % - 15-19 drinks - confusion - stupor 0.40 mg % - 20-24 drinks - coma, decreased body temp, resp depression, amnesia 0.50 mg % - 20-30 drinks - death caused by respiratory depression"

Reducing the Risk of Alzheimer's

"Staying physically active Stop smoking Avoid obesity, diabetes, hypertension and vascular disease Drink moderately or not at all Keep up your levels of Vitamin D Reduce inflammation Get enough sleep, but not too much Avoid chronic stress and depression"

Spirituality

"The human quality that gives meaning and sense of purpose to an individual's existence. Spirituality exists within each individual regardless of belief system and serves as a force for interconnectedness between the self and others, the environment and a higher power."

Antipsychotic Side Effects

-Anticholinergic -Antiadrenergic -Cardiac -EPS -Endocrine -Metabolic syndrome -Sexual -GI

Dementia: Clinical Picture & Prevalence

-Clinical Picture -Multiple cognitive deficits such as -Significant decline in the individual's previous levels of cognitive ability such as complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition" -Prevalence: --Alzheimer's disease - 60-90% of all dementias

Name the second gen, Atypical Antipsychotics

-Clozapine (Clozaril) - use declining b/c agranulocytosis and testing -Olanzapine (Zyprexa): WG, metabolic sympts -Paliperidone (Invega): elevated prolatctin -Quetiapine (Seroquel): sedation -Risperidone (Risperdal): elevated prolatctin -Ziprasidone (Geodon): QTC prolonged -Asenapine (Saphris): GI distrubance, akathesia -Ariprprazole (Abilify): 3rd gen b/c affects + and - symptoms and affective symptoms(mood) **serotonin-dopamine antagonists; treat positive and negative symptoms

meds to treat children and anxiety

-GAD: cymbalta -OCD: clomipramine (Anafranil), Prozac, Luvox, Zoloft

Assessment Guidelines

-Health care professionals mandated to report elder abuse and neglect to APS -Signs/symptoms of abuse -Fear of being alone with caregiver -Has signs of obvious malnutrition -Has bedsores or skin lesions -Is in need of medical/dental care -Reports abuse or neglect -Behaves in passive, withdrawn, or emotionless manner, sad, depressed

The Clinical Interview (3 parts)

-Initial phase -Working phase -Termination

Communication Guidelines for depression

-May need more time to reply -Make observations -Listen - covert messages -Question directly about suicide (address vague suicidal ideation)

Outcomes identification in Dementia/Alzheimer's Disease

-Patient will remain safe in the environment -Patient will communicate needs -Family members will have access to professional counseling -Patient will participate in self-care at an optimal level.

The Holistic Response to Stress

-Physical -Emotional -Intellectual -Social -Spiritual -Physical - increase HR, R, tense muscles -Emotional -anxiety, fear -Intellectual - worry, cognitive disorganization - hard to focus -Social - irritable, focus on self, not others -Spiritual - distress, maybe hopeless

Documentation: Key areas

-Problem -Physical status, vital signs -Systems assessment -Lab data -Risk factors -Mental Status Examination -Psychosocial status -Goals of patient and formulation of plan of care

Asking Why

-Puts patient on the defensive -Demands answer -Implies wrong doing or criticism -Example: Why did you do that? -Best approach: What is happening - explore the situation. -What were your thoughts when you did that?

NIC intervetnions for anger-control

-establish trust and rapport -calm, reassuring voice -determine pt level of cog and physical function -limit access to frustrating situations -monitor potential inappropriate aggression and intervene b/f expression -prevent psychical harm (retrain, remove weapons) -provide reassurance to pt nursing staff will intervene to prevent pt losing control -use external controls (timeouts, seclusion) as needed to calm pt

Assessment and Nursing Implications for schizo

Assessing patient response and need to change drug -compliance -Trial of 3-6 weeks: need to agree to this time -Is new drug from a different class? --may need long-term injectables -Use of long acting IM antipsychotics Nursing Implications -Use in pregnancy -Use by older adults -Side effects **class warning: increased death w/ dementia related psychosis

Somatization Disorder

Diagnosis requires certain number of symptoms accompanied by functional impairment --Pain: head, chest, back, joints, pelvis --GI symptoms: dysphagia, nausea, bloating, constipation, unable to swallow --Cardiovascular symptoms: palpitations, shortness of breath, dizziness Comorbidity -Anxiety and depression

Selective serotonin reuptake inhibitors (SSRIs)

Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) Fluvoxamine (Luvox) -SE: sex effects, N/V, GI -prozac: anorexic and antibulimic effects -paxil: contra in open angle glaucoma and pregs -the class blocks muscular and histamine receptors -less sedation and anticolinergic effects than TCAs

Psychological Factors

Freud (1930): sex and anger -thought was lack of sexual activity causing more violence Menninger (2007): Struggle for control causes anger, if control threatened =trauma= anger Trauma Informed Care: Identifies that people with disruptive violence often have hx that include violence and victimization. -need to have good past history to see if this pt has had a past of violence towards them, increases risk for them to be violent to others **can be learned behavior

Epidemiology and Comorbidity

Prevalence -6% of the global population -10% of the US population -Borderline PD in clinical setting - 10-20% of clients Co-morbidity -Often more than one PD diagnosed -50% of patients with mental illness diagnosis are diagnosed with personality disorder --if have deficit in personality makes sense you'd have mental illness, ex is pts w/ deficit can have abuse leading to PTSD or MDD

Addiction

Primary, chronic disease of brain reward, motivation, memory, and related circuitry.

DSM- 5

Religious or Spiritual problem -Loss -Questioning of faith -Problem with conversion to a new faith -Questioning of spiritual values

Stages of Alzheimer's Disease - Diagnosis

See Hallmarks of the following stages - -Mild Alzheimer's Disease - early stage: trouble w/ names, difficultly performing tasks for social or work, forgets material just read, losing things, trouble planning or organizing -Moderate Alzheimer's Disease - middle stage: forgets events or own history, mood or w/drawn, forgets address or phone number or high school they graduated from, need helping picking clothes for season, trouble w/ bladder and bowels, sleep patter off, risk of wandering around, suspicious or delusional -Severe Alzheimer's Disease - late stage: full time care needed, loss of awareness and surroundings, high care for ADLs, physical changes like can't walk, swallow, or communication, risk of infections like pneumonia

Substance Dependence/Addiction

· Continued use of substance despite problems (cognitive, physiological, and behavioral. · Spending more time in getting, taking, and recovering from the substance. · Continued use despite knowledge of physical or psychological problems or awareness of complications resulting from continued use of the substance. · Dependency can be both psychologic (needed to enhance coping) and physiological (discontinuance results in withdrawal signs and symptoms).

Neurocognitive Disorders Classifications

"Affect the brain's ability to function intellectually, emotionally, socially and occupationally." Delirium Mild neurocognitive disorder (MCI) Dementia (major neurocognitive disorder)

What are rights?

"a valid legally recognized claim or entitlement encompassing freedom from government interference or discriminatory treatment and an entitlement to a benefit or service"

Verbalizing the Implied

- puts into concrete words what patient implies -Pt: "I can't talk to you or anyone else. It's a waste of time." -Nurse "Do you feel that no one understands?"

Restating

- repeating same key words patient has spoken -Patient: "My life is empty it has no meaning?" -Nurse - "Your life has no meaning?" - Do not overuse restating. -Another question - -What does your life lack?

Fetal Alcohol Syndrome

-"Leading cause of intellectual disability in the US" -"Alcohol during pregnancy inhibits intrauterine growth & post natal development resulting in microcephaly, craniofacial malformations and limb and heart defects." -Women who drink have a 35% of defects in child

The Need for Spirituality

-"Seventy-three percent of Americans say that prayer is an important part of their daily life. Religious belief provides the power for an individual. With such beliefs so prevalent, it is no surprise that religious faith play a significant role in healing. -"Each nurse's exploration of his or her own spirituality and efforts to grow spiritually are foundational to being responsive to those needs in others." -"A solid spiritual foundation may help an individual confront the challenges that result from life experience's."

Seizures

-12 to 24 hours - post cessation of alcohol - grand mal seizures - give -Diazepam (Valium IV)

What are the Age considerations for an older adult during an assessment?

-5 senses and brain function diminish -do not stereotype or expect a deficit -may have special physical needs

Key Nursing Interventions for depression

-Accept pt: focus on strengths -Reinforce efforts to make decisions -For severe indecision, nurse makes decision -Never reinforce hallucinations/delusions -Anger management -Spend time with withdrawn patient -Provide activities designed for success -Safety

Tricyclic Antidepressants

-Action: 10-14 days b/c therapeutic, could be stimulating so given to pt who is fatigued -Common side effects: sedation, anticolinergic effects, cardiac -Adverse drug reactions: watch toxicity -Contraindications: heart complications, if on BC, narrow-angle glacoma, pregnant, hist of sz

Newer Atypical/Novel Antidepressants, action and advantages

-Action: affect variety of NTs including those affecting serotonin and norepinephrine -Advantage: --Can target unique populations of depressed individuals --Can be used to treat other conditions (like fibramyalgia)

Tactics for Milieu Management:Hallucinations/Delusions

-Approach with patient: let them know we see they're stressed -Patient's feelings -Clarify reality -Discourage talk of hallucinations/delusions: initially can recognize but decrease -Avoid arguing/attempt to reason -Use distraction: help develop distraction techniques -Concrete reality -Monitor TV selections: if they're extremely religiously preoccupied don't let watch religious channels, news can also be trigger

Antipsychotics Used with Bipolar Disorder

-Aripiprazole (Abilify) -Clozapine (Clozaril) -Olanzapine (Zyprexa) -Quetiapine (Seroquel): helps w/ sleep -Risperidone (Risperdal) -Ziprasidone (Geodon)

Nursing Interventions - Suicide for a Postcrisis Period

-Arrange for stay with family/friends; no one available -hospitalization -Weapons/pills removed -Encourage discussion of feelings -Avoid decisions during crisis -Community supports -If medication used- only 1-3 day supply and monitored by family/significant other

Barriers to Therapeutic Communication

-Asking excessive questions -Asking two questions at once -Giving approval and disapproval -Giving advice -Asking why -Giving false reassurance -Minimizing feelings -Making value judgments -Changing the subject

Alcohol Withdrawal on a Medical and/or Surgical Unit or ICU

-Assess for alcohol and substance use -Know patient may underestimate - I have just a couple of drinks -Watch for signs of any kind of substance withdrawal -Keen nursing assessment is the key to withdrawal prevention -Call the physician for any signs of withdrawal -Goal- to prevent withdrawal symptoms and keep patient safe

Six Steps of the Nursing Process

-Assessment -Diagnosis -Outcome identification -Planning -Implementation -Evaluation **ADOPIE

Depressive Episode for bipolar

-Atypical symptoms -Hypersomnia, daytime sleepiness -Hyperphagia (eating) -Weight gain -Craving for CHOs (carbs) -Leaden paralysis -Paranoid thoughts, hallucinations -Irritability, social isolation

Treatment for Personality Disorders: Medications

-Avoid benzodiazepines - due to dependency -Use medication with low toxicity --Antidepressants (SSRIs) --Lithium carbonate --Anticonvulsants --Low-dose antipsychotics

Cluster A: Schizotypal Personality Disorder

-Behavior or appearance is odd, eccentric, or peculiar --Odd, elaborate style of dressing, speaking, interacting -Magical thinking manifested -Unusual perceptual experiences -Lacks close friends -Excessive and unrelieved social anxiety -tend to ramble, lots of details, peeps can't understand them all the time -thinks people are out to get them or peeps are blaming them -overly superstitious -believing thoughts have ability to impart things on other people -could get hallucinations or delusions w/ this population -aware they're odd or excentric, aware of their magical thinking -more women -brain sim to schizophrenia, in spectrum

Stimulants Use Disorder

-Cocaine -Amphetamine -Methamphetamine -Swallowed, snorted, smoked, injected (are used second to cannabis) -Feeling: exhilaration, increased energy, elated, euphoric, sociable, super human (downside - hypervigilant sensitive, anxious, tense and angry) -Other effects: increased heart rate, blood pressure, body temperature, metabolism , paranoia, violent behavior and psychosis, mental alertness, tremors, and reduced appetite

Types of Discharges/releases

-Conditional Release -Unconditional Release -Release Against Medical Advice

High risk groups for substance abuse

-Men over women -Parent (genetics) -Caucasians (then native Americans, Hispanics and African Americans -Mental illness -Adolescents -Old age -Family and social environment where alcohol is present

Drugs used in Treatment of Opioid withdrawal

-Methadone - opioid agonist - given only in Methadone clinic - free clinic - have to go every day - treatment for heroin addiction - exchanging one opioid for another -Eliminates severe withdrawal and craving -safest if preg -If on Methadone and do Heroin - can get higher -SE: allergic reactions, pounding chest, hallucinations

Risk factors/Theories

-No single cause identified -Genetics: influence personality traits which may lead to personality, clearly associated w/ parents -Neurotransmitters: may regulate and influence temperament, not good understanding of it -Brain Imaging: Some differences in size and function of structures of the brain, diff in size Psychological Factors --Psychoanalytic theory: primitive or immature defense mechanisms are dominant (child-like) --Learning theory: Children learn maladaptive responses --Cognitive theory: beliefs and assumptions create create emotional and behavioral responses. Environmental Factors --Childhood neglect and trauma --Diathesis Stress Model: immediate influences on personality such as physical, emotional, and help understand how disorders emerge from genetics in environment -temperament: tendency to respond to challenges -stress includes what happens in past, unique exposures, growing up w/ fam, patterns of interactions -proposes that personality development becomes maladptive for some people resulting in emergence of personality disorder

Neglect by Care givers

-Not providing food, medication, medical treatment and/or personal care -Failure to recognize responsibility -Nurses responsibility for report

Milieu Interventions for depression

-Opportunity to experience accomplishment -positive feedback -Supportive group activities -Assertiveness training (not aggression) -Grooming and hygiene -Brief and frequent interpersonal contacts -Nutrition and elimination -Sleep patterns -Suicidal potential

DSM-5

-Provides criteria to diagnose psychiatric disorders -Classification system from APA --classifies disorders not people -Organized on a developmental hierarchy -conducted by psychiatrist, psychiatric-mental health advanced practice registered nurses, psychologists, licensed social workers, counselors, and marriage/family therapists **IDC-10-CM also used

Religion

-Religion is a set of beliefs in which spirituality may be expressed. " Affiliation with a religious group has been shown to be a health-enhancing endeavor."

What are Patients Rights Under the Law?

-Right to Treatment -Right to Refuse Treatment --(Exception: in an emergency) -Right to Informed Consent

IMPLICATIONS FOR PMH NURSES?

-need licensed nurse who after 2 yrs of fulltime work, 2000 clinical hours, and 30hrs cont CE, a BSN can take certification exam to be a BC psychiatric-mental health RN (PMH-RN)

INPATIENT CARE primary goal of inpatient care?

-stabilize crisis issue and least restrictive setting

INPATIENT CARE admission options?

-voluntary and involuntary -V: agrees to care -InV: doesn't agree --if acting out behaviorally, not criminally

Common Positive Symptoms

-when assessing need to start w/ + symptoms -Defined as the florid psychotic symptoms --Hallucinations --Delusions: identify type of delusion (paranoid, persecutory, nihilistic, ideas of reference) --paranoia --disorganized thoughts -Impaired abstract thinking -Associative looseness -Personal boundary difficulties -Bizarre behavior

Torts

-wrongful harm against person, property or reputation, can seek $ for damages -Intentional Torts - willful or intentional acts that violate another person's rights or property --assault, batter, false imprisonment -Unintentional Torts - unintended acts against a person that produce injury or harm

Assessment of Delirium

1. Cognitive and Perceptual Disturbances 2. Physical Needs 3. Moods and Behaviors

Psychiatric Mental Health Nursing Holistic Assessment

1. Establish rapport 2. Identify patient's problem 3. Review physical status and obtain baseline vital signs Review of systems (see Medical Conditions That May Mimic Psychiatric Conditions- Page 113, Box 7-3) Laboratory Data 4. Assess risk factors affecting the safety of the patient or others 5. Perform a mental status examination 6. Assess psychosocial status 7. Identify mutual goals for treatment 8. Formulate a plan of care 9. Document in retrievable format

What are the QSEN Competencies?

1. Provide patient centered care 2. Work in interdisciplinary teams 3. Employ evidenced based practice 4. Apply quality improvement 5. Utilize informatics

Phases of therapeutic relationship

1.)Preorientation Phase 2.)Orientation Phase -Introduction (Rapport, contract, confidentiality) 3.) Working Phase 4.) Termination Phase

Mild Cognitive Impairment: Prevalence

6% of people in 60's have MCI 37% by age 85 15% of 65 or older go to full dementia Indefinite on how long it takes to progress to dementia

Assessment: Spiritual History

A simple spiritual history can be taken: Acronym HOPE H - sources of hope, strength, comfort, meaning, peace, love and connection 0 - The role of organized religion for the patient P - Personal spirituality and practices E - Effects on medical care and end-of-life issues A convenient way for a health care professional to take a spiritual history: Puchalski's FICA questions F - Faith - what is your faith tradition? I - Importance - how important is your faith to you? C - Church/Community - what is your church or community of faith? A - Address - how might we address your spiritual needs? "one simple question" "Do you have any spiritual needs or concerns related to your health?" Other Resources: (1) Another nurse who has comfort talking about spiritual concerns (2) clergy/chaplain

Screening Tests for Alcohol Use

AUDIT - Alcohol Use Disorders Id Test SBIRT - screening, brief intervention, referral to treatment, used for at risk pts CAGE - questions for pts Warning signs of alcohol use disorder: Frequent drinking sprees, increase intake, drinking alone, early morning drinking, blackouts (functions socially but lacks memory of event)

Treatment of Delirium

Address underlying physiological and psychological etiologies Complete recovery will occur if physiological etiology is addressed (Example: Delirium from pneumonia) If not addressed dementia and death may follow.

Alcohol -What does it do to the body?

Affects every system - Systemic effects Alcoholic Myopathy: muscle weekness Peripheral Neuro from nutritional deficiencies Alcoholic Cardiomyopathy - symptoms similar to heart failure -Fatigue, shortness of breath and edema in legs and feet Esophagitis: veins at risk for busting=med emerg. Gastritis: n/v, loss of appetite, bloating

Hans Selye's Theory

Alarm Resistance Exhaustion

Psychosis

Altered cognition, perception, and or impaired ability to determine what is real. Other psychotic disorders: Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizoaffective Disorder Substance Induced Psychotic Disorder and Psychotic Disorder due to another medical condition oSubstance Induced Psychotic Disorder and Psychotic Disorder due to another medical condition: due to high BP, hyponatremia, etc or drugs (including steroids)

Types of Neurocognitive Disorders - Dementia

Alzheimer's Disease Frontotemporal dementia Dementia with Lewy Bodies Vascular Traumatic Brain Injury Substance-medication induced Continued HIV Infection Prion Parkinson's Disease Huntington's Disease

TCA antidepressants

Amitriptyline (Elavvil) Imipramine (Tofranil) Nortriptyline (Pamelor) -SE: anticolinergic effects = blurred vision, dry mouth, tachycard, urinary retention, constipation --can be fatal and toxic

Terminology

Anger: response to frustration or threat to one's needs, perceived or actual --can be good if channeled correctly -self-reflection is very important Aggression: action that causes verbal or physical attack. May be considered positive. -can be self protective, not always involving violence Violence: act that involves intentional injury -goal is to harm someone **anxiety often precipitates negative feelings and behaviors

Child and Adolescent: Anxiety and Mood Disorders

Anxiety Disorders (Review Chpt 15) -Separation anxiety disorder: happens in preschool children, not just scared but think something detremintial will happen to them or caregiver if separated --requires therapy not meds -Posttraumatic stress disorder: treated same as adults, offer therapy and anti-anxiety meds, manage panic attacks Mood Disorders (Review Chpt 13 and 14) -Major depressive disorder -Disruptive Mood Dysregulation Disorder: common in kids, negative attitude, no suicide ideation or attempt -Bipolar disorder: adult diagnosis, can see traits in children so be vigilante

Delirium Assessment: Cognitive and Perceptual Disturbances

Assess level of consciousness, neurological signs Assess for cognitive impairment Assess for attention deficits (easily distracted) Memory impairment Misinterpretations of reality-illusions, hallucinations illusions -errors in perception of external stimuli ( mistake window blind cord for a snake) hallucinations - visual - false sensory perception (see spiders on the wall)

Nursing Process, ADHD, and Disruptive Disorders

Assessment guidelines -Are you allowed to talk with children alone? No parents and children both need to give permission, can do alone but need parents permission --protect self -What are the rights of the child? --kids have no rights legally, all decisions should be made by parents or someone legally capable of making these decision Common nursing diagnoses -Ineffective Family Coping/Individual Coping -Caregiver Role Strain --difficult on entire family process Nursing Interventions -Child/adolescent: need to learn delayed gratification and coping skills -Parent/caregiver: provide help w/ respite care, understand their role, choosing their battles, making home a place where they don't fight, needs lot of support, referrals, and resources

Nursing Process: Assessment and Diagnosis

Assessment: -pts not hospitalized usually unless medically related, many scales use depending on situation -Self assessment: enable pt to do self-assessment -Primary vs secondary anxiety --primary: true anxiety, true feelings --secondary: aka secondary gain, situation causes us to get attention so we develop anxiety to get that continued attention -look for Potential for self harm/suicide -Psychosocial aspects -Cultural beliefs and background: any fam hist, poverty, financial stress strain, anxiety common in culture or treatment allowed? -Valuable NANDA Diagnoses -if OCD, rituals can interfere w/ assessment, if we interrupt compulsion process we create more anxiety so we need to allow it to occur b/c its a coping mechanism

Nurse's Role with Aggressive and Violent Behavior

Assessment: Check behaviors, monitor body language, hx of violence, current psychosis or mania, aggression if limit setting occurs, hx of lack of coping skills, substance w/drawal, overcrowded unit, inexperienced staff, poor limit setting or inexperienced staff -need self-assessment as nurse, listen to tone of voice, verbal and nonverbal cues, how are you effecting the situation Diagnosis: Risk for other-directed violence, Risk for self-directed violence, impaired impulse control Planning: being able to address current coping skills and willingness to learn new skills. -help them to identify they are anger and there's non-violent ways to handle these feelings

Implementation during nursing assessment

Basic -coordination of care -health teaching and health promotion -milieu therapy -pharmacological, biological and integrative therapies Advanced -prescriptive authority and treatment -psychotherapy -consultation

Atypical/Second Generation Antipsychotics

Bind to dopamine receptors in the limbic system Decrease motor (extrapyramidal) side effects -used for schizo Atypical Antipsychotics -Clozapine (Clozaril) -Risperidone (Risperdal) -Quetapine (Seroquel) -Olanzapine (Zyprexa) -Ziprasidone (Geodon): heart issues -Aripiprazole (Abilify) (Thought to be more like 3rd generation) -Paliperidone (Invega) -Iloperidone (Fanapt) -Lurasidone (Latuda) -Asenapine (Saphris): sublingual **metabolic syndrome and agranulocytosis

Neurobiology of Alzheimer's 2

Brain Dysfunction - -Amyloid plaques - sticky clumps found between nerve cells -Neurofibrillary tangles - Abnormal collections of protein threads inside nerve cells -Brain atrophy - cerebral cortex shriveling up

o Substance-induced obsessive-compulsive and related disorder

Characterized by obsessions and compulsions that develop with the use of substance or within a month of stopping use of the substance. Drugs use to treat Parkinson's disease have been reported to cause obsessions with gambling, irresistible urges for sex, and out-of-control spending.

Delirium

Clinical Picture: short term and reversible -constellation of symptoms (syndrome) -medical emergency -can result in longer hospital stays or death Acute cognitive syndrome Often reversible Alteration of consciousness Disorganized thinking -needs immediate intervention to prevent irreversible damage -associated w/ increase morbidity and mortality and can have perm. cog decline

Older Adult Abuse: Nursing Diagnosis and Planning

Common nursing diagnoses: risk for violence, ineffective coping, caregiver stress Planning: -Arrange for housing services -Obtain medical services -Address personal needs -Provide service coordination -Serve as patient advocate, if person of abuse is power of attorney get social services involved

Cultural Barriers

Communication Failure to assess cultural perspective Stigma Differences in World View Misdiagnosis --Cultural mismatch

Assessment

Construct database: -mental status exam -psychosocial assessment -physical exam -history taking -interviews -standardized rating scales verify data

Nursing Interventions for suicide for a crisis period

Crisis Period -Follow institutional protocol --Suicide precautions: 1 on 1, line of sight, etc --Suicide observation -Accurate records of patient behavior, documenting activity q 15 min or as per protocol -No suicide contract: let staff or fam know -Discussion of feelings/problem solving alternatives

Accurate Diagnosis: "Comparison of Delirium, Dementia, and Depression"

Dementia Depression Delirium Note: All three diagnoses may be present in the elderly. It is important to have an accurate diagnosis prior to treating the patient.Facts on Aging

Dementia Types

Dementia - generalized Dementia: Alzheimer's type Dementia: Parkinson's Disease Dementia: Huntington's disease

Psychopharmacology used to maintain sobriety

Disulfiram - antabuse -interferes with breakdown of alcohol in liver =If drink or come in contact with alcohol in any way - become very sick -violent reaction such as pounding in the chest, drop in b/p, nausea and vomiting, facial flushing and potentially death - behavioral method to stop drinking - helps prevent relapse of alcohol abuse - takes 14 days for the drug to leave the body Naltrexone (Vivitrol)- reduces alcohol cravings and the high by blocking the release of endorphins - helps block drug cravings (ReVia - oral) Acamprosate (Campral) - helps reduce some of the unpleasant symptoms of abstinence (anxiety, agitation, dysphoria) - helps with craving Buphenorphine (Suboxone) - used with opioids

Etiologies of Delirium

Drug intoxication Infections Metabolic Disorders Drugs Neurological diseases Tumors Psychological Stressors

Emotions/Feelings

Emotions are a normal response to stress Emotions can be managed We are responsible for our own feelings and emotions "You made me feel this way." We choose to feel the way we want to feel. Change our thoughts, we can change our emotion.

Scope of Aggression and Violence

Epidemiology: CDC (2015) reported 60,000 violent injuries treated in healthcare settings. -nurses are huge target -ICU, psych, or geriatric units most common Co-morbidity: PTSD, Substance Abuse Disorders -older adults have shorter fuse, could be due to level of metabolic syndrome -pts w/ bipolar have difficulty w/ anger and aggression Anger and aggression are risk factors for HTN, cardiac complications, ischemic strokes

Health care concerns of the older adult

Financial burden Caregiver burden Ageism Losses

Scheduled Drugs

Five schedules - based on the drug's acceptable medical use and drugs misuse potential -lower the # = higher the potential of abuse I: high abuse, no medical use, heroin, LSD II: high abuse, dangerous, prescription only, methadone, Demerol, Ritalin III: low-mod misuse, Rx only, testosterone, acetaminophen/codeine (Tylenol w/ codeine) and Suboxone IV: low risk, Rx, IV xanax, ativan, darvocet V: contain limited amounts of narcotics, treatment for diarrhea, coughing, pain, Lomotil, Robitussin AC, Lyrica

Etiology

Genetics: Biologically predisposed to anger, irritability and easy frustration to life events -could be from toxin in environment or illness that effected mother Neurobiological: Brain tumors, dementia, TBI, temporal lobe epilepsy, Huntingtons Chorea --anything that effects amygdala (emotional center of brain) causes anger (in the limbic system) -amygdala: emotional center, evaluates emotional content of experiences, id's potential threats (higher vol=more aggression) Neurotransmitters: serotonin, GABA, and dopamine -serotonin: can stim aggress. behavior depending on part of brain -dopamine: if have too much =aggression -GABA: can reduce aggressiveness, why anger pts treated with antianxiety meds

Guidelines and treatment for Schizoid Personality Disorder

Guidelines -Do not try to increase socialization, do not have desire to do so -Focus on coping and anxiety: for things like work -Help to avoid embarrassment: don't ask them to read allowed, etc -Avoid being too kind or too friendly Treatment -Often reject treatment, don't think its necessary -Psychotherapy: to develop a trusting relationship and develop social cues -Group therapy: even though the pt will likely not participate, still can benefit, can gain more info about social skills -Medications: Antidepressants (Wellbutrin) and antipsychotics (risperidone or Zyprexa) may increase pleasure and emotional responses. --pts often don't desire to have any adjustments in their personality

Guidelines and treatment for Dependent Personality Disorder

Guidelines -Help identify stressors -Be aware of time mgt., they can be needy of others time -Focus on helping role model assertiveness -Build rapport, very good boundaries w/ this pt -countertransference can occur b/c pt often in crisis Treatment : -psychotherapy: choice treatment -CBT -Meds: no specifics --Antianxiety agents --TCA's

Nursing Process in Dementia/Alzheimer's Disease

Holistic Assessment Physical/Behavioral - Total History and physical Mental/Intellectual - Mental Status exam Emotional - mental Status exam Social - subjective and observation Spiritual - subjective and observation Data source: Patient and family -Confabulation - creation of stories to maintain self-esteem -Perseveration - repetition of phrases or behavior -Aphasia - loss of language ability -Apraxia - loss of purposeful movement -Agnosia - loss of sensory ability to recognize objects -Agraphia - inability to read or write -Hyperoality - need to put everything in mouth -Hypermetamorphosis - touching everything in sight

Nursing Process: Evaluation for panic

Identified outcomes: basis for evaluation -Anxiety reduced -Patient connecting symptoms with anxiety -Symptoms still present: how often present -Newly learned behavior: experiences secondary gain -Performance of self-care activities: ADL -Maintaining satisfactory relationships -Resuming usual roles -Med and treatment compliance: taking meds

Delirium assessment -physical

Identify disturbances in physiological status (infection, hypoxia, pain) Assess for injury related to falls or wandering Pulling IV's Falling out of bed Self - care deficits Hyper or hypoactivity Changes in sleep/wake cycle Assess for vital signs =Autonomic Nervous system signs - tachycardia, increased blood pressure, dilated pupils

Nursing Process: Implementation

Interventions -Milieu management -Pharmacological management -Case management -Nurse needs to understand difficulty with creating therapeutic relationships --Give choices --Orient to reality --Teach behaviors that build on existing skills -Use established interventions for manipulative, impulsive, and aggressive behaviors

Examples of interventions in the implementation stage

Interventions for a injury - safe environment Interventions for self-care needs Interventions for communicating Interventions for social needs Interventions for home care

Substance use disorder

Maladaptive pattern of drug use leading to impairment or distress, as manifested by one or more of these circumstances within a 12-month period (e.g. social, school, or occupational): · Disease of dysregulation in pleasure seeking or reward pathway of the brain. · Inability to consistently abstain from substance or activity. · Lack of insight. Unable to recognize extent to which addictions are creating serious problems in functioning, interpersonal relationships, and emotional responses. · Cycles of relapse and remission. · Progressive. Without treatment, results in disability or premature death. Substance - Any mind altering drug.

Detoxification (detox)

Medically managed inpatient program with 24-hour medical coverage while the patient's body clears itself of drugs. Patient may have uncomfortable or fatal side effects caused by withdrawal. The goal is safe and comfortable detox.

Cognition

Memory Abstract Thinking Judgment -Cog functioning: -executive functioning (problem solving) -learn and retain info in long-term memory -use language -visually perceived the environment -read social situations (social cog)

Diagnosing of a Change in Cognitive Functioning

Mental status exam Medical work up

Neurocognitive Disorders 2

Mild Neurocognitive Disorders (MCI) Major Neurocognitive Disorders (Dementia)

Nursing Diagnoses (Nanda)

Moral distress Hope Hopelessness Religiosity - Religiosity, impaired Religiosity, readiness for enhanced Spiritual distress, impaired Spiritual distress, risk for Spiritual well being

The Role of Psychopharmacology in Psychotherapeutic Management

Need Effectiveness: evaluate effetiveness Combined with other interventions Side effects: make sure pt understands this Use as "crutch": try to use short term only Trial and error

Treatment of Alzheimer's Disease

No cure Medications - -Cholinesterase inhibitors can help delay or prevent symptoms from becoming worse for a limited time (wane after 1-2yrs) --inhibit breakdown of ACh --Cognex, donepezil, rivastigmine, glantamine -Antidepressants - for depression -Antipsychotics - used sparingly to control behavior (not prescribed anymore) --Start low --Go slow --Monitor closely

Nursing Diagnoses in Dementia/Alzheimer's Disease

Nursing Diagnoses: Risk for Injury Impaired verbal communication Impaired environmental interpretation syndrome Impaired memory Chronic confusion Ineffective coping Harm to self and others Compromised or disabled family coping Caregiver role strain Anticipatory grieving Self-care deficit

Opioid Addiction - Public Health Crisis

ONSET: Believed to be physicians overprescribing opioid pain medications 64,000 drug overdose deaths in 2016 Sharpest increase - deaths from Fentanyl and Fentanyl analogs (synthetic opioids) (20,000 overdose deaths) Drug overdoses are the leading cause of death for Americans under 50. On the street Fentanyl is added to heroin for a stronger high Fentanyl is 50-100x more potent than heroin Drug users to not always know what they are taking

Sundown syndrome

Occurs with delirium and dementia Symptoms become worse in the evening and night Irritable, confused, disoriented, demanding, suspicious, anxious, wandering Nursing diagnosis: -Risk for injury - provide safe environment -Disturbed Sleep Pattern - calm, restful environment, dim lights, music, regular routine -Anxiety (severe, panic) - decrease stimuli, short sentences, one person speak, distraction -Acute confusion - give simple directions

o Hair pulling disorder is called trichotillomania

One of the oldest psychiatric problems. Typically hair from the head is taken off but hair can be pulled from anywhere on the body. Hair pulling ranges from patches to complete baldness. Pulling results in anxiety reducing. Trichophagia, is secretly swallowing the hair, is common. This can be fatal and can build up masses in the GI tract. o These two disorders have linked symptoms of OCD. This occurs more often in children than adults.

Nursing Process: Outcomes and Planning

Outcomes Identification: -Change may be slow and occur with trial and error -Establish modest, obtainable goals Planning: -Often seen in healthcare settings for other reasons, w/ exception of borderline personality disorder

Alcohol - systemic effects

Pancreatitis Alcoholic Hepatitis Cirrhosis of the Liver Leukopenia Thrombocytopenia: from cirrhosis Cancer Gastritis Peripheral Neuropathy

Panic Disorders

Panic Attack -Sudden onset of extreme apprehension or fear of impending doom; fear of losing one's mind or having a heart attack --last minutes, come out of blue Panic Disorder without agoraphobia o A sudden onset of extreme apprehension or fear, usually associated with feelings of doom and terror. o These people believe they are losing their minds or having a heart attack. o Palpitations, chest pain, breathing difficulty, nausea and feelings of choking, chills and hot flashes may occur. o They are unpredictable in children and adolescents. Normally they last about 10 minutes. o Since this is uncontrollable for most people there is a sense of hopelessness in controlling the attacks. o Alcohol and substance abuse is common in adolescents with this disorder. o Cormobs of hyperthyroidism, dizziness, arrhythmias, asthma, chronic obstructive pul disease (COPD), IBS

Another example of cultural differences

Patient speaking in tongues (1) Gift from God? (2) Psychosis? -Important to do a good cultural assessment and history. -Caution: Cultural imposition - The nurse imposing own cultural norms on members of other cultural groups.

Delirium: Evaluation

Patient will remain safe Patient will be oriented to time, person and place by discharge The underlying cause will be treated and ameliorated

Monamine Oxidase Inhibitors (MAOIs)

Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline (ENSAM) **tyramine food interactions = HTN crisis

Planning with Dementia/Alzheimer's Disease

Planning is geared toward the individual's immediate needs Plan for families needs: meals on wheels transportation referrals to a day care center support groups respite and residential services home health services

Dissociative Identity Disorder (DID)

Presence of two or more distinct personality states that take control of behavior (alter) --Alter or subpersonality has own pattern of thinking, perceiving, and relating --Principal personality (core) unaware of others -Precipitated by severe sexual, physical, or psychological trauma --primitive ego defense mechanism (emotional part and normal part are not connected) **more females than males -High risk for suicide and self harm -some alters can be dangerous and want to kill host personality -comorbs: MDD, anxiety, panic attacks, eating disorders, PTSD, somatoform symptoms, OCD, etc -brain issues in limbic syst and hippocampus -one state blocks all trauma, alter is fixated on trauma, each alter has its own memories, behavioral patters, social relationships, diff race -host doesn't know about alters, loses time and doesn't know why -shifts brought on by stress

Disorders in Children and Adolescents

Prevalence --One in five children and adolescents --More than ½ of lifetime cases of mental illness begin before age 14 (screening very important, questions, suicide, etc) This is a specialized field that requires specific education. There are many barriers to treatment --Wait and see approach (b/c kids brains are constanly changing) --Lack of coordination of care --Lack of community based resources --Lack of providers --Cost of treatment and inadequate reimbursement (very expensive)

Mental Health Nursing Care and Culture

Psychiatric mental health nurses need to adapt to the culture of the individual - culturally competent care -Ask patient and family views on mental health problem - Ask to share their cultural views, past coping patterns and health seeking behaviors -Identify sources of support and strength - Asian cultures usually depend on extended family in a crisis -Negotiate treatment according to the person's cultural views Campina-Bacote: made blue-print for psych healthcare, says nurses are constant learners -cultural awareness: recognize bias -" " knowledge: understanding -" " encounters: don't stereotype -" " skill: meaningful conversation, use cultural assessments, use conversational technique instead of direct questioning, promote openness, be culturally sensitive in care-plan, attempt to re-pattern or restructure unhealthy patterns in culture and if neutral encourage to keep -" " desire: not acting out of sense of duty but out of genuine concern, inspires openness and flexibility

Treatment for Dissociative Disorders

Psychotherapy -Primary treatment offered, most effective -Techniques include psycho-education, talking through trauma, safety planning, journaling, artwork Medications -Anti-depressants, mood stabilizers, anti-psychotics, anti-anxiety medications for co-morbid conditions and sx. -can use somatic therapy, dance movement, etc, trauma stored physically as well

Spiritual care and the nurse patient relationship

Qualities of the nurse: caring, respectful, genuine, compassionate, nonjudgmental, trustworthy, good listener. Role of the nurse in spiritual care (1) respond to patient cues (2) ask open ended questions (3) listen

Nursing Diagnoses: Delirium

Risk for injury as evidenced by sensory or perceptual deficits Acute confusion related to delirium Risk for deficit in fluid volume Sleep deprivation Impaired communication Fear Self-care deficit

Additional antidepressants

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) --Venlafaxine (Effexor) --Duloxetine (Cymbalta) --Desvenalfaxine (Pristiq) **watch for HTN Serotonin-Norepinephrine Disinhibitors (SNDIs) --Mirtazapine (Remeron) --SE: WG, sedation --used in elderly for sleep and eating Serotonin Modulator and Stimulator --Vortioxetine (Trintellix) --increases cog in older adults --SE: constipation, N/V, hyponat Serotonin Partial Agonist and Reuptake Inhibitor --Vilazadone (Viibyrd) Other Antidepressants --Bupropion (Wellbutrin, Zyban) --Trazadone (Desyrel) ----Wellbutrin: used for smoking cessation ----SE: insomia, tremor, WL ----trazadone: sedation, ortho hypo, dizziness, priaprsm

Somatic Symptom Disorders

Somatoform disorders -Physical symptoms in absence of physiological cause -Associated with increased health care use -more common in hosp. -constantly coming to treatment, but no reason they would require the treatment, unexplained nausea or pain -usually related to psychological disorder, from abuse or trauma -not diagnosed as often b/c seen as difficult pts to docs Factitious disorders -Consciously pretending to be ill to get emotional needs met and attain "patient" status

Delirium: Implementation

Some interventions would include Monitoring neurological status and vital signs Keep patient safe Keep communication simple and direct Acknowledge feelings Maintain well-lit hazard free and low stimulus environment Assist with personal care Orient patient to the environment

Herbal/Vitamins

St. John's Wort: can take for depression Gingko Balabo: risk of bleeding w/ warfarin Kava Fish Oil: can decrease depression Vitamin D and B

Drug Treatment for Attention Deficit Disorders

Stimulants -Methylphenidate (Ritalin and Daytrana) -Dexatroamphetamine (Adderall and Vyvanse) --SE: aggression, increased BP and HR, decreases growth and cog, anorexia Non-Stimulants -Atomoxetine (Straterra) -Guanfacine (Intuniv) -Clonidine (Kapvay) --SE: WL, fatigue, dizziness, sleepiness, irritability, nightmares

First Generation Typical/Conventional Antipsychotic Drugs

Strong Antagonists (blocking agents) Antagonists of receptors for acetylcholine, norepinephrine, histamine -increase dopamine, used in schizo -used for positive symptoms Extrapyramidal side effects --Akinesia --Akathesia --Parkinsonism --Dyskinesia --Tardive dyskinesia --Abnormal Involuntary Movement Scale (AIMS ) **Haldol, thorazine, prolix

Tolerance

Substance tolerance is the need for greatly increased amounts of the substance to achieve the desired effects or markedly diminished effect with continued use of the same amount of substance; substance tolerance does not occur with all substances.

o Obsessive-compulsive or related disorders due to a medical condition

Symptoms of obsessions and compulsions are a direct physiological result of a medical condition. • Ex: traumatic brain injury, cerebral infarctions, Huntington's disease, etc. • In order to know if symptoms are due to a medical condition, a careful and comprehensive assessment of multiple factors is necessary.

cultural concepts of distress

Take into account way groups experience, understand and comm problematic behaviors, suffering, or troubling emotions and thoughts, DSM takes 3 local constructs into account: -cultural syndromes -cultural idioms of distress -cultural explanations pharmacogenetics: research being done to see how meds effects diff races

Codependence

Term came from research on families dealing with alcohol, need to assess for this Cluster of behaviors -"Overly responsible" -Over doing for the other -Low self-esteem -Not paying attention to own needs -Attempting to control use -Finding excuses for the substance user -Eliciting promises to change Term could be applied to caretakers, nurses, spouse or anyone who fits the above characteristics

Emotions or Feelings

Thoughts - Feelings - Behaviors What precedes an emotion? Thought Threat perception perceived depends on coping skills, past experience, amount of threats at once, age and other factors Feel anxious - (see levels of anxiety in Chapter 15) Mild, moderate, severe or panic Cognitive (thinking, focus) and physiological symptoms involved

Additional Child/Adolescent Mental Health Disorders

Tic Disorder -Tourette's Disorder: shouting, tics, tremors, grunting Feeding and eating disorders -Pica -Rumination disorder -Feeding and eating disorder in infancy/childhood

Child, Intimate Partner, and Elder Abuse

Types of Abuse -Physical -Sexual -Emotional -Neglect -Economic -crisis situation: situation that puts stress on family w/ a violent member

o Skin picking disorder is called dermotillomania

Typically confined to the face. People do this to deal with stress and relieve anxiety, while other engage in this without thinking about it. Complications include pain, sores, scars and infections. o These two disorders have linked symptoms of OCD. This occurs more often in children than adults.

Polysubstance use

Use of three or more drugs, or a combination of alcohol and drugs.

Assessment Validation

Validating Assessment -can validate finding with medical records, police reports, previous psychiatric admittance reports --old histories can give baseline for behaviors and functioning -Rating Scales: since a lot of subjective info, can use to standardize info -Indicator for Suicide Self-Restraint (NOC outcomes, ranges from 1-5 w/ actions, 1 never demonstrated to consistently demonstrated)

Alcohol withdrawal treatment - protocol on the Integrative Care Unit at Community North Hospital, Indianapolis

Watch for increase vital signs, tremors, agitation & other withdrawal symptoms- assess q four hours using the CIWA scale See CIWA scale in Module Resources administers lorazepam (Ativan) accordingly to CIWA results If doesn't fall within the CIWA guidelines - call the doctor Give Ativan 1-4 mg taper IM or PO to prevent withdrawal Replacing one CNS depressant for another CNS depressant Stay on top of withdrawal by good assessment

Western and Eastern Cultures

Western Culture - eye contact, feeling expression, promoting independence, individuality Eastern Culture - less or no eye contact, express feelings somatically, reliance on family, women look to the husband for decision making -somatization occurs b/c mind-body seen as one

Pharmacological, biological, & integrative therapies as basic intervention

applies current knowledge to assessing pts response to meds, provides med teaching, and communicates observations to other members of HC team

Genetics and Neurobiological risk factors

oGenetics: 80% of risk factors come from genetics oNeurobiological: first gen meds block dopamine shows symptom reduction in positive symptoms, second gen block dopamine and serotonin which identifies schizo has role w/ both neurotransmitters -amphetamines, cocaine, PCP, and marijuana bring on psychosis

Health teaching & maintenance as basic intervention

-individualized anticipatory guidance to prevent or reduce mental illness or enhance mental health (e.g. community screenings, parenting classes, stress management)

Voluntary Admission

-informal: no paperwork, least restrictive of all, doesn't pose threat to self or others, pt can stay or go at anytime -vol. admin: paper done, need to understand reason for admit, can request and obtain relase as right, decision can result in invol admin from PCP

Spirituality and Mental Health Nursing

-large volume of contemporary research (more than 60 studies) demonstrating the value of spirituality for both medical and psychiatric patients..." -Freshwater, 2006, stated there is a positive correlation between mental health and spiritual wellness. -Brown and colleagues (2013) examined the relationship between religious coping styles and spiritual well-being with the psychological variables of anxiety and depression. Their study showed that people who report 'higher levels of religiosity and spiritual well-being may also experience a reduction in mental and emotional illness.'

Cluster A: Schizoid Personality Disorder

-lifelong patter of w/drawal, expressionless and have restricted range or emotional expression -Neither desires nor enjoys human relationships, like to be alone (lifelong w/drawal) -Fixated on personal thought/fantasies -Demonstrates emotional coldness, detachment, and flat affect -Indifferent to praise or criticism, no emotional response -Chooses solitary activities, like being at home and away from people --can still have positive relationships but rare, have imaginary friends and fantasies --rather be observer of life than participator --have trouble holding down jobs, doesn't do well in school

What Biochemical factors/neurotransmitters are involved in depression?

-main two are serotonin and norepi -serotonin: regulates sleep, appetite and sex --if dysfunction = poor sleep, poor appetite, low sex drive, and low impulse control, more irritable -norepi: regs attention and behavior, modulates stressful situations --if deficient= apathetic, reduced motor response, eating more -cognitive: if negative/pessimitic view of world increase for depression

Interventions for sev to panic anxiety

-maintain calm manner -remain w/ person -use clear and simple language -use low-pitched voice; speaks slowly -reinforce reality if distortions occur -listen for themes in communication -attend physical and safety needs if needed -set psychical limits if need and speak in firm authoritative voice -provide opportunities for exercise -offer high cal fluids -asses need for meds or seclusion after other interventions have been tried

DBT (dialectical behavior treatment)

-mash linehan -for chronically suicidal pts -combines cognitive and behavioral techs w/ mindfulness, emphasizes being aware of thoughts and actively sharpening them -goal to increase ability to distress and improve interpersonal skills -targets: suicidal behavior, therapy interfering behavior, quality of life behaviors

Mental health Parity

-mental health equal treatment w/ insurance -Mental health parity Act passed in 1996 -Wellstone-Domernici Parity Act in 2008 for group plans w/ more than 50 employees -ACA helped w/ mental health insurance

Coordination of care as basic intervention

-coordinates implementation of nursing plan and docs coordination of care -meds, discharge, accesses to care, follow up

Milieu therapy as basic intervention

-provides, structure, and maintains safe and therapeutic environment in collab w/ pts, families, and other HC clinicians -look at pt interactions and safty of environment

Intoxication

- Substance intoxication is a reversible, substance-specific syndrome caused by recent ingestion of/or exposure to a substance resulting in maladaptive behavior or psychologic changes from effects on the CNS.

Potentiation

- Two or more substances interact in the body to produce an effect greater than the sum of the effects of each substance taken alone (e.g., alcohol and another CNS depressant). Anxiolytics and phenobarbital potentiate each other (one plus one = ?).

Projective Questions

- start with "what if... -Helps patient articulate, explore and identify thoughts and feelings. -way of facilitating patient's thinking differently about a problem -Examples: " What if you could go back and change how you acted in that situation, what would you do differently? "Of all things you said - what is the bothering you the most?" **can ask the miracle question, " what if you didn't have this illness or problem, how would life be different?" helps identify goals

Monoamine Oxidase Inhibitors (MAOI's)

-Action: inhibit enzyme for monoamines (serotonin, dopamine, neuro), cannot break down tyramines in liver if taking --use in pts w/ treatment resistant depression -Common adverse reactions: tyramine=HTN crisis, sexual dysfunction, vertigo, manic/hypomanic, increase BP, risk for intercranial hemorrhage -Potential toxic reaction --Hypertensive crisis: occurs 50-90min after injection of food -s/x: irritability, flushing red skin, restless, fever, sz, coma, death -contra: HTN, liver failure, heart disease, if on eltriptivan and dopamine

Selective Serotonin Reuptake Inhibitors (SSRIs)

-Action: selectively block neuronal uptake of serotonin -Common adverse reactions: sexual, GI distress, increased suicidal thinking -Potential toxic effects --Serotonin syndrome (SS): potentially fatal reaction when more than one antidepressant used, its too high --can occur if given with 2 serotonin drugs like SSRI + MAOI, need to discontinue one drug 2-5wks b/f given other

What is the MOA for Atypical Antipsychotics? Advantages and disadvantages?

-Action: serotonin and dopamine antagonist -First atypical introduced: clozapine (clozaril) Problem: agranulocytosis -Advantage of atypicals -Alleviate positive and negative symptoms -Minimal EPS -Help improve cognitive deficits; decrease anxiety and depression -Disadvantages of atypicals Weight gain -Metabolic syndrome -Expense -BLACKBOX: Increase mortality in elderly with dementia-related psychosis

Tactics for Milieu Management: Withdrawn Patients

-Activities: not isolated -Setting -Decision making: help pick out clothes, etc -Socialization -Grooming and hygiene -Psychosocial rehabilitation -Groups **pts w/ prominent neg symptoms

Phases of Rape-Trauma Syndrome (PTSD), high correlation w/ acute stress disorder

-Acute phase: psychiatric response to serious trauma or violation -recurrent symptoms of flashbacks, triggering events, negative thoughts or mood, dissociative symptoms where experience altered sense of reality, avoid lots of things (emotions, location), may not be able to remember parts of trauma, difficulty falling asleep or staying asleep -Long-term phase: depression, suicide, anxiety, fear, difficulties w/ ADLs, low self-esteem, sexual dysfunction, somatic physical complaints -if lasts more than a month= PTSD --can feel disconnected from everything, like watching self from above, depersonalization/derealization -acute stress disorder: psych reaction to trauma or witness death, suffering serious injury, sexual violation --sympts start 3 days after, last less than a month 5 categories of sympts: --intrusive, negative thoughts/mood/feelings, dissociative sympts, avoidance, arousal sympts

Anticonvulsants

-Adjunct to lithium as well as treatment for patients not responsive to lithium or major SE (can be use as monotherapy) Commonly used drugs: -Carbamazepine (Tegretol) --works for rapid cyclers, paranoid angry pts, monitor liver enzymes, need blood counts (leukopenia common) -Divalproex Sodium (Depakote), pill --monitor liver func., platelet count, causes WG, transient hair loss -Gabapentin (Neurontin): more so used for anxiety -Lamotrigine (Lamictal): only FDA approved for maintainence, won't throw into mania and treat depression, assess body for rash (steven johnson's syndrome) -Oxcarbazepine (Trileptal) --if had SE w/ tegratol -Topiramate (Topamax): helps w/ WL not used by itself -Valproate Sodium (Depakene), syrup -Adverse effects of anticonvulsants vary

Neurobiology of Addiction

-Affects Brain Stem, limbic systems, and frontal lobe -Neurotransmitters - especially dopamine -All drugs affect the reward pathways in different ways directly or indirectly = send false message of pleasure -Dopamine ability to stimulate the reward center can be ineffective over time - then there is a need for increase of drugs to affect reward centers - -Tolerance -Responds to Natural Rewards and Drugs -The brain chemistry changes in the brain with drugs -addiction: primary, chronic, disease of brain reward, motivation, memory and related circuitry

Characteristics of Older Adult Abuse

-Age-related syndromes resulting in frailty and functional decline increase susceptibility to abuse -Older than 80 - 2 to 3 times as likely for abuse -Older women more likely than men -Caretaker stress and burden -Most like abuser in intimate partner violence -Most cases done by family members --get overwhelmed so neglect care or get physically assaultive w/ pt

Alcohol withdrawal treatment

-Alcohol withdrawal - usually 3 days -Clonidine order if high blood pressure -Meds - Thiamine, Folic acid (alcohol interferes with absorption and are deficit in alcoholics Post detox: -Change of thinking, coping - needs support for long term sobriety -Rehabilitation for Relapse prevention (relapse 2-3 times is common) -Partial hospitalization, intensive outpatient, outpatient -Alcoholics Anonymous -Alanon for Family -Groups, Therapy

Med Guidelines for Children

-All anti-depressants can cause increased suicidal ideations in children/adolescents (Black Box warning-see next slide), need education every time prescribed, or meds adjusted, MUST document -Meds are dosed on age and weight -Children can be more sensitive to medications as their brains are actively developing --often need lower doses -Compliance is an issue: don't remember to take meds, parents leave it up to kid or parent chooses to not treat symptoms -Not treating sx can be detrimental

Guidelines for ADHD Pharmacology

-All stimulants can become dependent and habit forming. (discuss and educate pt and family) --watch for signs of sub. abuse, lock meds if people come over -Drug holidays with stimulants should be encouraged. -Parents/family with hx of drug abuse should be monitored -Parent need to be educated about how to store and administer stimulant medication Stimulant and non stimulant medications side effects -Weight loss; anorexia -Impaired appetite -Worsen tics, tremors -Elevated Blood Pressure -Impaired sleep -Elevated heart rate -Irritability **if pt not getting enough sleep, not getting enough growth hormone release --take meds b/f 12pm if stimulant --give more energy =increased irritability, tell pt's parents to look out for this if kid getting more and more irritated, then need to adjust meds

Dissociative Disorders

-Altered mind-body connections associated with stress and anxiety --depersonalization/deralization disorder --dissociative amnesia --dissociative identity disorder Prevalence -Unknown: estimated from 5%-20% among psychiatric patients Comorbidity -PTSD, borderline personality disorder (BPD), childhood sexual abuse, attention deficit disorder

Treatment of Stimulant Withdrawal

-Amphetamines - inpatient necessary -Treat the symptoms: -antipsychotics for psychosis, -Valium for agitation and hyperactivity; antidepressants with depression (bupropion Wellbutrin) -Cocaine withdrawal - intense craving - may need hospitalization, no physical symptoms --1-2weeks for w/drawal --fatigue, mood changes, craving, depression

Medications for Side Effects of Antipsychotics

-Anticholinergic --Benztropine (Cogentin) --Trihexyphenidyl (Artane) **if on too high dose, get impaired cog. function -Dopamine Agonist --Amantadine (Symmetrel) -Beta blocker --Propranolol (Inderal) **for physical SE, more relaxed and calm -Benzodiazepines (not for substance abuse pts and caution with clozapine) --Clonazepam (Klonopin): long term --Lorazepam (Ativan): acute **increased risk of decreased resp if have sub abuse -Antihistamine - used in IM form for rapid relief of acute dystonia; used to treat akathisia when sedation is needed --Diphenhydramine (Benadryl)

Common NANDA Diagnoses

-Anxiety -Interrupted family processes -Risk for suicide** -Risk for other-directed violence -Ineffective coping -Risk for self-mutilation** (for borderline personality disorder its big) -Social isolation -Hopelessness and/or powerlessness -Impaired verbal communication -Risk for loneliness -Chronic low/situational low/or risk for low self esteem

Working Phase (Nursing Process)

-Assessment (data gathering) --Problem --Thoughts/feelings/Suicidal/homicidal --Behavior (non-verbal) --Symptoms -Diagnosis -Planning: Establish a nurse patient relationship to develop trust and involve patient in goal setting -Implementation -provide education about disorder and meds -Assist with goal setting (promoted symptom management) -Assist with Problem solving and self-esteem -Evaluation of progress -Document results -Additional data gathering ex: Diagnosis: Risk for suicide as evidenced by suicide attempt -Prioritize nursing diagnoses -Outcomes Identification -Long term goal: Patient will remain free from injury throughout hospital stay -Short term goal: Patient will seek out staff when feeling overwhelmed and/or having thoughts of self-injury

Nursing Process and Culture

-Assessment of patient's culture Do a culturally sensitive assessment interviews (interpreters) Cultural Assessment tools -Nursing Diagnosis (the accuracy of the nursing diagnosis will be based on the thoroughness of the assessment) -Outcomes Identification (Identify attainable and culturally expected outcomes) -Planning (will be culturally relevant and compatible with cultural beliefs and values) -Implementation Do Culturally specific interventions. -Evaluation (document data - reevaluate - Additional data? Reassessment? - revision of plan?)

Nursing Process in Delirium

-Assessment: physical and neuro exam, get info from fam, review meds, pt attention decreased, orientation off -illusions, hallucinations, and perceptual issues -pt may try to get up and leave, secure lines -put clocks, glasses, etc up for pt -look for self-care deficits: poor nutrition, skin breakdown, etc -SNS symptoms can occur, watch sleep cycle -range from hyper-vigilance to hypersomnia -liable moods -pt can wonder off, watch safety, can by hypervigilant -Diagnosis: risk for injury, acute confusion, risk for deficient fluid vol., sleep deprivation, impaired communication -Outcome Identification: keep pt safe and oriented -Implementation: treat cause, physical restraints if needed, limit decision making, simple communication but direct, low-stim enviroment, encourage sensory aids (glasses, hearing aids), approach pt slowly and from the front

What's the mental health continuum?

-At one end is mental health: well-being is general condition (adequate to high level of functioning, no serious impairments) -opposite end is mental illness: mild-moderate distress

Cluster B: Histrionic Personality Disorder

-Attention grabbing, self-dramatizing expression of emotions, excitable, very high functioning, very colorful personality -Very egocentric, have difficulty building relationships w/ others b/c high idea of self or smothers their partners or are insensitive -Seek lots of attention -Sexually provocative clothing/behaviors -Excessive concern with appearance -Extreme sensitivity to others approval -False sense of intimacy with others (difficult to maintain relationships, too much for signifs) -Constant sudden emotional shifts -Impressionistic speech lacking detail -don't see treatment for their personality disorder but do see treatment for anxiety and depression

Neuro-Developmental Disorders

-Autistic Spectrum Disorder: extremely specialized for treatment, treating symptoms not diagnosis -Communication Disorders -Intellectual Disability -Motor Disorders -Specific Learning Disorders S/x: -lack of responsiveness or interest in others, empathy or sharing -lack of cooperation or imaginative play w/ peers -speech delay, repetitive speech -can't feed, bathe, dress, or toilet self at age-appropriate level -head banging, face slapping, biting -disregard for bodily needs -failure to follow age-appropriate social norms -depression-refusal to attends school -can't concentrate, w/drawal, diff functioning, feeling down, vegetative symptoms -fam over protective, lack of knowledge, interferes w/ child's autonomy, has anxiety

Patient and Family Education

-Basic facts about illness -Signs of relapse -Medication effects and side effects --Importance of regular lithium levels -Coping with symptoms and identify when out of control -Providing support

Withdrawal and treatment

-Begin within a few hours to several days -Symptoms: tiredness, vivid nightmares, increased appetite, insomnia or hypersomnia, psychomotor retardation or agitation -Functionally impaired during withdrawal -Depression and suicidal thoughts - most serious side effect of stimulant withdrawal -Cocaine - psychological withdrawal

Common Negative Symptoms

-Changes in affect -Apathy -Anhedonia: lack of pleasure in things that used to give them pleasure -Anergia: lack of energy -Avolician: lack of motivation -Poor social functioning -Poverty of thought/ thought blocking -Lack of goal directed behavior -Affect **absence of something that should be present

Cluster A:Paranoid Personality Disorder

-Believe others are lying, cheating, or exploiting them, someone's out to get them --hypervigelent, overly jealous, unwilling to forgive, controlling, feel partner is hyper-critical even if not -Perceive hidden malicious meaning in benign comments -Inability to work collaboratively with others -Emotionally detached -Hostile to others: jealous, trolling -sympts start in childhood: no friends , odd, teased **can precede diagnosis of schizo

What are the Ethical Principles that are important in bioethics?

-Beneficence -Autonomy -Justice -Fidelity -Veracity

Etiology of Anxiety Disorders

-Biological theories --Genetics: if raised by anxious parent, at greater risk --GABA benzodiazepine (BZA): has lack of GABA, slows neurons and reduces anxiety, meds are made to increase GABA --Hypothalamus-pituitary -adrenal dysfunction: very common --Brain anatomy change -result of repeated trauma, makes brain anatomy change and puts pt at risk for anxiety -Learning and behavioral theory -Cognitive theory -Cultural considerations: we identify anxiety more here in U.S more readily than other mental illness, more common and accpeted -Adaptive and Malap -chronic anx=CVD, can be disabling -pts w/ it use rigid, repetitive, and ineffective behaviors to control anxiety

Etiology of Substance Use Disorders

-Biological/genetic --Alcohol - 40-60% - risk of inheriting an alcohol addiction --Fourfold increase in risk in children from affected individuals -Neurochemical - neurotransmitters involved in all drugs except alcohol -Neurobiology of Addiction - "The Reward Pathway" - important --Tolerance and Addiction - Naloxone's action with Heroin Overdose-physiology in the brain - important -Environmental - chronic stressors, peer pressure for adolescents -Sociocultural - alluring lifestyle of users - different views of alcohol in different culture

WHAT IS THE ROLE OF THE PMH NURSE?

-Biopsychosocial assessment -Case management -Promoting continuation of treatment -Teamwork and collaboration -THERAPEUTIC MILIEU -Multi-disciplinary team member -Members of each discipline are responsible for gathering data and participating in the planning of care -Treatment plan or clinical pathway provides a guideline for patient's care during hospital stay

Types of Bipolar Disorder

-Bipolar I: At least one episode of mania alternating with major depression, most hospitalized -Bipolar II: at least 1 Hypomanic episode(s) alternating with major depression --Not accompanied by psychosis -Cyclothymia: Hypomanic episodes alternating with minor depressive episodes; symptoms have occurred for at least 2 years and without remission for more than 2 months --not as common -Specifier from DSM-V: Rapid cycling (four or more episodes in a 12-month period) --have more sev symptoms, more diff to treat, resist some traditionally offered meds

Alcohol Intoxication

-Blood alcohol level may be high and person is not showing signs of drinking -Increased tolerance. May take several drinks of hard liquor for example to get the high. -Standard drink - takes body one hour to detoxify hard liquor - 1.5 oz (shot) = 1 drink -Wine - 5-6 oz = 1 drink -Beer - 12 oz = 1 drink Absorption & detoxification - one hour for one drink Signs of being intoxicated happen sooner if drink faster (more than one drink an hour)

Common Law suits against Psychiatric nurses

-Breach of confidentiality -Invasion of privacy -Assault: verbal threat -Battery: actual harm -False imprisonment Breach of confidentiality: charge of defamation of character -liable: info in writing -slander: oral defamation of character **occurs in charting, needs objective information and meticulous detail Invasion of privacy: body searches w/out probably cause assault and battery: treatment of client against their wishes (outside of emergency situation) --harm or injury needs to occur for these charges to be legitimate False imprisonment: confining pt against his/her wishes outside emergency situation

Neurocognitive Disorder /Dementia, What is it?

-Broad term to describe progressive deterioration of cognitive functioning -Collection of symptoms due to an underlying brain disorder -When progressive, disorder interferes with cognitive functioning (executive functions, such a problem solving, complex attention) and memory

Alcohol Use Disorder

-CNS Depressant --Sedative -initial euphoria -Severity on the number of symptoms --Mild - 2-3 symptoms --Moderate - 4-5 symptoms --Severe - 6 or more **must have for 1yr

Commonly Used and Abused Drugs

-Caffeine -Nicotine -Cannabis (Marijuana) -Inhalant Use Disorder -Opioids -Stimulants Use Disorder -CNS depressants (Sedatives, hypnotics, antianxiety drugs) -CNS depressant - Alcohol drugs not in lecture Club drugs Hallucinogens Dissociative drugs

assisted oupt treatment

-Can be a preventive measure, allowing a court order before onset of a psychiatric crisis that would result in an inpatient admission -usually tied to "goods" and "services" (welfare, disability, housing) -To access these goods and services patient is mandated to participate in treatment and may face inpatient admission if they fail to participate

Competency

-Capacity to understand the consequences of one's decision -Legally competent -Incompetent - has a legal guardian -person is legally competent until been declared incompetent by formal legal proceeding -if incompetent, legal guardian appointed

Treatment for Somatoform Disorders

-Case management -Psychotherapy --Cognitive and behavioral therapy --Group therapy helpful (learn coping, assertiveness, cog reframing, prob-solving, social supports Medications --Antidepressants (SSRIs), benzos --Short term use of antianxiety medications - dependence risk -person feels stressed, feel like they're being mislead or not taking care of b/c they believe they have a physical disorder not a mental one

Nursing challenges and examples

-Challenges - personal life, institutional resources Examples related to: --Lack of respect: nurse not actively listening, has boredom, referring to pt by room # not name --Lack of accountability: not checking on pt but chatting w/ other pts --Lack of availability: not listening to pt, on iphone, not attending to pt's needs, nurse shows signs of stress --Blurring of boundaries: pt takes care of nurse Couter-transferance reactions: -boredom -rescue: reaching for unattainable goals, giving advice -over-involvement -over-identification: special agenda, keep secrets, physical attraction, self-disclosure -misuse of honestly: w/holding info, lying -anger" w/drawing, speaking loudly -helplessness, hopelessness

Evaluation

-Change outcomes as needed to reflect deterioration of functioning -Purpose of outcomes - are to promote the patient's optimal level of functioning -Work close with family

Guidelines for Nursing Intervention for Elder Abuse

-Check state law regarding elder abuse and report suspected abuse -Involve Adult Protective Services -Meet with other family members and others to identify stressors -If no family members, notify other community agencies that may help abuser and elder -Encourage abuser's use of counseling

Name the Traditional Antipsychotics

-Chlorpromazine (Thorazine) -Loxapine (Loxitane) -Perphenazine (Trilafon) -Thiothixene (Navane) -Fluphenazine (Prolixin) -Haloperidol (Haldol) **Traditional /conventional antipsychotics - dopamine antagonists; treat primarily positive symptoms

Treatment of Alzheimer's Disease: Pharmacological

-Cholinesterase inhibitors -galantamine (Razadyne) -donepezil (Aricept) -rivastigmine (Exelon) -NMDA Receptor Antagonist: regs activity of glutamate -memantine (Namenda) -NMDA Receptor Antagonist/Cholinesterase -Inhibitor donepezil and memantine (Namzaric)

Dysthymic Disorder (DD), now called Persistent Depressive Disorder

-Chronic depressive syndrome usually present for most of a day, more days than not, for at least a 2-year period -When you think about this disorder think of Eeyore -low energy, poor self-esteem, poor outlook -SSRIs and SSNRIs -use of psychotherapy and gratitude training (using gratitude as way of healing)

Cluster B: Antisocial Personality Disorder

-Chronic irresponsibility and unreliability -Lack of regard/ violation of law and rights of others -Persistent lying and stealing for personal gain -Conning others for personal gain -Lack of remorse for hurting others -callousness, profound lack of empathy -Reckless disregard for others' safety -deceitful and manipulative for personal gain or hostile if needs blocked -has criminalist behavior -shallow, unexpressive, superficial affect or charming -aka sociopath, has to be 18yrs old for diagnosis -diagnosis for an adult but do see in teenage yrs(peak at age 20), around age 40 people tend to approve just because of age -profound lack of empathy for others, very superficial affect (callousness) -could be witty, charming, seductive, but only for gain for what they want, need to identify if they're trying to manipulate someone --can have empathy for selves but not others -genetically linked, inherit aggressive-disregard (violent tendencies w/out regard to other) -can be culturally biased

Risk Factors for Suicide

-Co-morbid medical condition (chronic) --especially eating disorders, schizo and PTSD -Substance Abuse/Dependence -Psychosis, command hallucinations -No positive protective factors --Hopelessness, helplessness, worthlessness -Presence of plan, previous suicide attempt -Impulsive, aggressive tendencies -Family history - suicide, violence, abuse -Incarceration -Exposure to suicidal behavior of others -race: whites -religion: decreased risk -marriage: decreases risk -profession: professionals have higher risk -health: chronic illness increase

Nursing Process: Assessment Neuro disorders

-Collect data about nature, location, onset, characteristics, and duration of symptoms --assess nutrition and elimination, pts complain about GI probs --do symptoms only happen during sev. stress -Ability to meet basic needs -Secondary gains, do they get this or primary gains -Ability to communicate emotional needs ( often lacking) -Determine medication/substance use -Self-assessment: we may have neg feelings b/c we think pt is faking, its real to them so we need to not be judgemental -sympts not unconscious, pts don't know they're not feeling these things, some things are vol. so determine which are those things -conversion disorders = pts are matter of fact, and somatic disorder = pts use exaggerations or metaphors

Nursing Process : Diagnosis, Outcome Identification, and Planning

-Common Nursing Diagnoses: ineffective coping, fear, powerlessness, low self-esteem, risk for violence, rape -trauma -Outcomes Identification: abuse ceased -Immediate concern: any other people in house being hurt -General outcome -Intimate Partner Abuse: Realistically, leaving the abuser is not usually the decision made by the woman; therefore, referrals for safe houses, hotlines, and support groups are important --make referrals -Planning: Ensure victim has a basic safety plan (money, insurance cards, people to contact), a way out when they're ready to take one --even very acculturated person can revert back to cultural past in coping w/ stressful event, need to speak slowly and w/out jargin

Asking excessive questions

-Common for novice because of anxiety -Slow down -Let patient talk - do not interrupt -Listen to the patient -Put in back of mind what you want to explore, clarify or focus -explore aspects of what the patient is saying --Focus --Clarify **can look like an interrogator, doesn't allow pt to collaborate

Diagnosis, Outcomes, Planning

-Common nursing diagnoses: shame, guilt, helplessness, powerlessness -disturbed personal identity, interrupted family process, sexual identity disturbance, sexual dysfunction, anxiety, fear, social isolization -Outcomes identification: pt move from victim to survivor mentality (takes a long time), not under acute distress, feel calm and safe --expressions of right to have been protected from abuse, healing of psychical injury, relief of anger in nondestructive ways, feelings of empowerment and expressions of hope, evidence of comfort in relationship -Planning: unless physical or psych injury treatment off and pt released -plan of care has info for follow up care

Diagnosis, Planning, Implementation, Evaluation

-Common nursing diagnosis assigned: ineffective coping, pain, social isolation, risk for suicide -Outcomes identified -Matter-of-fact approach -Long-term treatment/interventions: refer out to psychiatry for help and assistance -need to make sure pt understands they have a pscyhological disorder -Focus interventions on establishing relationship -Case manager - avoids "doctor shopping" -Collaborate with family w/ education -Communication Guidelines -Common for goals to be partially met -teach coping skills -promote self care (pt who thinks they're blind can still feed themselves, describe plate as clock)

Assessment of Dementia/Alzheimer's continued

-Diagnostic Tests -Brain imaging with PET scan and Mental status exam --CT also used -Progression - See table on Stages of Alzheimer's Disease -mini mental status exam -Self-Assessment *depression can be co-morb, often confused for alzheimers

Mental Health Laws

-Differ from state to state -Started in the 1960's with civil rights movement & community mental health movement -Guideline: humane care while respecting civil rights -Civil rights of persons with mental illness (due process) -Admission and discharge procedures -Pts rights under the law -Mental health laws providing parity which is insurance funding for mental illness

Diagnosis, Planning, Implementation

-Common nursing diagnosis: based on safety, ineffective role perform, anxiety, self-control, risk for self-directed violence -Cambridge depersonalization scale, Dissociate experience Scale , Somatoform Dissociation Questionnaire -Planning - focus on safety and crisis interventions when hospitalized -3 phase model: 1: safety, stabilization, symptoms reduction 2: confronting, working through, integrating traumatic memories 3: Id integration and rehab -Common goals: interacting w/ others, taking meds as prescribed, not requiring restraints or seclusion, not suicidal -Interventions -Milieu management: watching for changes in mood and behaviors, helping pt identify triggers -Health teaching: make sure they're safe -no meds but can use antidepressants, antianxiety, anti-psychotics -CBT, EMDR -Evaluation: long term treatment and eval, want to put all alters into host personality, could take years -asses history for self-harm -evaluate level of anxiety and signs or dissociation -ID support systems through psychosocial assessment -refer pt to therapist **no spec meds, some used to calm hyper-arousal like antidepressants, anti-anxiety, anti-psychotics

Emergency Care and Crisis Stabilization provider?

-Comprehensive emergency service model --asses in ER if mental health crisis -Hospital-based consultant model --nurses/ psych consulted, give meds, and other needs -Mobile crisis team model --go into population when needed -Crisis stabilization/observation units --all major metros have them, asses if further level of care needed

Other Self-Destructive Behaviors

-Concept of self-mutilation (cutting) -Characteristics of self-mutilators: often have underlying personality disorder, attention seeking -Self-mutilation and suicide: high risk of suicide even if didn't mean to -Self mutilation and other psychiatric disorders --common with DID and borderline personality disorder

Factitious Disorder

-Consciously pretending to be ill or pretending someone else is ill (by proxy) to meet an emotional need. -problem of compulsive and constantly hide true nature of illness -injury themselves, can get septic from so many immunization their given in hospital hopping -use very specific medical terms -Munchausen syndrome and Munchausen syndrome by proxy -Factitious disorder by proxy -Malingering: conscious act of fabricating or exaggerating sx for secondary gain. -make up symptoms, may be homeless, need gain, insurance money, etc -reported pains are vague and hard to disprove -Illness can be physical or psychiatric --more common in men, associated w/ narcissistic, antisocial, borderline personality disorder

Lithium Carbonate Patient and family teaching

-Continue drug therapy to prevent relapse -Maintenance of normal diet with normal salt and fluid intake ( 1500-3000 mL/day) --Lithium decreases sodium absorption and low sodium levels/dehydration cause lithium toxicity -Stop taking lithium and call physician if symptoms of dehydration develop from sweating and /or nausea, vomiting, diarrhea (b/c risk toxicity) -Take at same time daily and suggest taking with meals -Suggest drinking 10-12 glasses of water daily -Lithium level: morning blood draw - 8-12 hours after last dose -Discuss side effects that are transient and identify side effects that require reporting (N/V, thirst, polyuria, lethargy, sedation) -Discuss not driving until stabilized -If edema - elevate legs

What are the BASIC LEVELS OF INTERVENTION?

-Coordination of care -Health teaching & maintenance -Milieu therapy -Pharmacological, biological, & integrative therapies

Continuum of Care

-Crisis intervention -Inpatient -Referral -Outpatient - groups, home health

Review of Concepts of Culture and Cultural Competence

-Culture: manifestation beliefs, values and norms of an individual, group or community used for daily life functioning. -Cultural competence: process whereby the nurse develops cultural awareness, knowledge, and skills to promote effective health care for patients. -Cultural diversity: unique differences in areas such as age, gender, socioeconomic status, religion, race and ethnicity. -cultural norms: attitudes and behaviors considered normal, typical, or average w/in a group -minority status: subset of people who think of themselves and are thought of by others, as a differentiated group -race: defined biologically, anthropologically, or genetically, distinguished visually -ethnicity: have heritage and history in common, hare worldview

Nursing with Seclusion & Restraint

-Deescalate the patient's anxiety through a calm approach and listening -May seclude and restrain in an emergency but need doctor's orders ASAP -Alternative must be considered -Seclude and/or restrain for the shortest possible time

Anxiety - definition

-Definition - feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized. -Vague sense of dread relating to an unspecified danger -Universal human experience -Basic of all emotions -Adaptive or maladaptive response (defense mechanisms) -Experienced in levels

False Imprisonment

-Definition: "Deliberate and unauthorized confinement of a person with fixed limits by the use of verbal or physical means (Ellis and Hartley , 2012) -Health care workers can be charged for restraining and secluding against the wishes of the patient

Therapeutic Communication Techniques

-Definition: words and actions of the nurse that help to achieve health related goals -Applied to all of nursing -Purpose: --facilitates patient toward achieving health related goals -helps patient explore thoughts and feelings -helps the patient problem solve, learn coping behaviors ** can be applied Outside of nursing

Mental Illnesses related to Aging

-Depression -Depression and suicide risk -Bipolar disorder -Anxiety disorders -Post Traumatic Stress Disorder -Psychotic symptoms (delusions/hallucinations related to dementia or delirium) -Substance use disorders

Substance withdrawal

-Development of a substance-specific syndrome resulting from a cessation or reduction of substance use that has been heavy and prolonged (e.g., alcohol withdrawal). -Alcohol is a CNS depressant; therefore, the opposite symptoms occur during withdrawal, including: · Increased vital signs. · Agitation, restlessness. · Tremors, diaphoresis, nausea, and vomiting. -Without intervention, withdrawal from alcohol could progress to seizures and hallucinations. -Severe withdrawal (Delirium Tremens) is a medical emergency.

Diagnosis and Outcomes with suicide

-Diagnosis -Goals -Relevant Nursing Outcomes Classification (NOC) -Plan of care **need to come up with different plan than just for depression, suicide needs to be identified as its own thing

Concerns for healthcare

-Difficult to prove -Need to identify adverse childhood experiences (ACEs): divorce, trauma, drug related issues -Self care of the nurse is important as this will be a frustrating illness to treat as it is a conscious control, also needs a lot of support, produces anger -It will be essential for the nurse to work with allied health care professionals and department of children's services (if biproxy)

Cluster C: Dependent Personality Disorder

-Difficulty with decision making -high need, patterns of submissiveness w/ fears of separation and abandonment -Others assume responsibility for person's life b/c they're so dependent -Fear of disagreeing with others b/c they don't want to be left alone (gives intense anxiety) -Preoccupied with fear of being left alone -incidence is rare

Cannabis or Marijuana

-Directly affects the brain of the user -Effects - euphoria, relaxation, slowed reaction time, distorted sensory perception, impaired balance and coordination, increase HR, increased metabolism, impaired learning & memory, anxiety, panic attacks, psychosis -Particularly dangerous for adolescents for brain effects, slowed cognitive functioning. -intoxication: heightens sensations, bright colors, times slows, depresonalization and derealization, red eyes, dry mouth, tachycardia marked impairment, motor skills impacted for 8-12hrs -Health risks - respiratory infections, mental health decline, addictions. -Withdrawal: occurs w/in 1wk of stopping, irritability, anger, aggression, anxiety, restlessness, depressed mood, insomnia and disturbing dreams can occur w/out it --physical s/x: ab pain, shakiness, sweating, fever, chills, HA -Diagnosis: Cannabis stored in fatty tissue - will show up in drug screen after 4 weeks of previous use -Treatment - Abstinence and support - hospitalization or outpatient - support group therapies

Release Against Medical Advice

-Disagreement between provider and patient -In cases where treatment seems beneficial but there is no compelling reason to seek an involuntary continue of stay * Release depends on the patient's admission status

Privileged Communication

-Disclosure of patient information in certain circumstances -patient proposes a serious danger to another -Abuse rape incest or other crimes -Patient consents to release of information -court mandates the release -Information is needed by other caregivers -Know state laws on reporting child abuse and elder abuse -Pts who are suicidal needs to be put on precautions -Patients should be protected from other patients -Domestic violence may need to be reported to authorities **duty to protect and warn

Depressive Disorders

-Disruptive Mood Dysregulation Disorder -Persistent Depressive Disorder -Premenstrual Dysphoric Disorder -Substance/Medication-Induced Depression -Depressive Disorder Due to Another Medical Condition (cancer, chronic med conditions, etc)

Peplau's Model of the Nurse Patient Relationship

-Dr. Hildegard Peplau introduced the nurse patient relationship in 1952. -Book: Interpersonal Relations in Nursing -helps nurse and pt alleviate suffering, find solutions, explore different avenues to increased quality of life, or find an advocate -"facilitates forward movement" -created 4 interlocking, overlapping phases

Other Treatment for Bipolar Disorders

-Electroconvulsive Therapy (ECT) Psychotherapy -Cognitive-behavioral therapy -Interpersonal therapy -Family - focused therapy

Manic Episode Symptoms for bipolar

-Elevated mood for at least 1 week -Elevated self esteem, grandiosity -Decreased need to no need for sleep -Speech pattern-rapid, pressured -Poor concentration and easily distracted -Psychomotor agitation (restless, anxious) -Mood disturbances-labile (good mood to bad mood, to irritability) -Marked impairment in functioning - hospitalization: impulsivity is what gets them hospitalized

Major Depressive Disorder: Common Symptoms

-Emotional and cognitive symptoms -Physical Symptoms: N/V, Assessment of: -Affect: objective, different than mood -Thought Processes: logical? -Mood: what you say it is (subjective) -Feelings -Cognitive Changes: confused, slow to respond, thought blocking, etc -Physical Behavior: eye contact, withdrawing

Cluster B: Borderline Personality Disorder (BPD)

-Emotional dysregulation (can't differentiate difference between mother dying and crashing their car) -Stormy relationships with anger and fighting -Persistent unstable self-image -Use of splitting -Frantic efforts to avoid real/perceived abandonment -Emotionally labile -Impulsive self-destructive behaviors --Frequent suicide attempts, chronic ideations --Self-mutilation (cutting), can overdo it =suicide --substance abuse --promiscuous sexual behaviors --damage property **common in inpt setting, most dramatic of personality disorders -Use of splitting: inability to view both positive and negative aspects as part of the whole, someone is wonderful or horrible --try to use staff splitting by being manipulative, saying one nurse is better than another, better to assign just one staff person -genetic: hypersensitivity, implusivity, emotional dysregulation -shorter allels for serotonin transporter -abnorm. prefrontal and limbic -psych: separation of mother-child could effect (Mahler) -high mortality from suicide -decreases w/ age, w/ high rates of remission and low relapse -more woman -co-morabs of DM, high BP, chronic back pain, fibromyalgia, arthritis

Major Depressive Disorder (MDD) criteria for DSM

-Emotional, cognitive, physical, and behavioral symptoms occurring nearly every day for at least a 2 week period Review DSM-V Diagnosis

Empathic Statements

-Empathic or empathetic statements -"It sounds like you are having a difficult time." -"This must be very hard for you."

Termination Phase

-End of relationship (discharge, end of shift) -Summarize goals and objectives acheive -Review learning (and situations that occured) -Discuss plans for future (new coping, next steps) -Work through feelings about termination (exchange memories to validate experience) -Referral

ED Intervention Guidelines for Intimate Partner Violence

-Ensure medical attention provided -Proper protocol for evidence -Interview patient in private -Assess in nonthreatening manner information about: sexual abuse, chemical abuse, thoughts of suicide or homicide -Encourage patient to talk about incident, and carefully listen -Assess if pt has safe place to go -Identify if pt wishes to press charges and facilitate this process -If patient is not ready to take action, refer to community resources, emergency numbers -Be sure patient understands legal rights and inform of legal protections -involve police if neglect or abuse, can't force pts to do or get treatment, provide suggestions

Scope of Abuse

-Epidemiology --Child abuse --Intimate partner abuse --Older adult abuse -Comorbidity: sub abuse, untreated mental illness or PD -Family violence -Perpetrator: person who participates in violent behavior, usually see themselves as having poor social skills -Victim: Vulnerable (abused) person

Concept of Sexual Assault

-Epidemiology: under-reported, 1 in 5 women, b/b age 25 w/ first rape b/f age 18, half vics are person they knew, 60% of pts who have been raped have been under influence of drugs and alcohol -Act of violence, not sex: about control -Greatly under-reported -Comorbidity -More vulnerable individuals -Psychological effects -Theories related to perpetrator --believe they're unhappy w/ lack of self-esteem and feel lack of control -completed or attempted -completed rape: penetration of vagina, anus, or other body part with an object or oral penetration from another person w/out consent -attempted rape: threat or intention of rape was present but penetration did not occur --if got rufied (GHB) but not assaulted

Long term effects of stress produce disease

-Essential hypertension Stroke Atherosclerosis Diabetes Cancer Ulcers Chronic GI problems Allergies/eczema Autoimmune diseases Arthritis Headaches Reduces immunity Kidney and liver diseases

Limited decision making capacity

-Ethical principle - Autonomy -Need for informed consent -Guiding principle: protection and ensure needs are met and rights protected -Advance care planning -power of attorney -legal guardian Elderly &/or those with limited decision making capacity -Abuse - physical, psychological, medical, financial, discrimination or abandonment -Neglect - mistreatment through failure of action **violation of human rights

Nursing Process: Evaluation

-Evaluate short term indicators and outcome criteria -Reduction on suicidal thoughts -Able to state alternatives to suicide -Decrease in severity of emotional, cognitive, and vegetative/physical symptoms of depression

Nursing Process: Evaluation for Survivors of Violence

-Evaluation of interventions based on: --Whether survivor acknowledges violence, is willing to accept intervention, or is removed from violent situation (cognitively or physically able to understand abuse) -Important that multidisciplinary team be involved in providing services to victim, abuser, and other involved family member (case-managers, pharmacologist, etc) --Follow-up is essential in helping decrease frequency of family violence --make sure perpetrator is getting the treatment they need **good physical and assessment is key to identifying these issues

False Reassurance & Minimizing feelings

-Everything will be all right. -Shuts off communication -Best approach; Listen, empathy, offer support -Minimizing feelings -You are not the only one who has felt that way. -I know just how you feel, this happened to me too. -Best approach: Center on the patient and listen Know patient's experiences are unique to patient

My Visit to South India

-Evil spirits causing mental illness =go to a witch doctor - seen in villages -Many get mental health care in the government hospitals in larger cities -Visited a large government hospital in Chennai - -Western medical model used with same meds used in the US -Many individuals from India come to the US for medical education to be a psychiatrist - stay in US - higher standard of living and salaries. -Shortage of psychiatrists in India 3500 psychiatrists for over a billion

Generalized Anxiety Disorder (GAD)

-Excessive free floating worry, out of realm of what normal worry should be, anxiety or worry about numerous things lasting at least 6 months -Common symptoms: lots of worry that impairs ability to have adequate relationships, jobs, time spent preparing for worry, lots of lateness or absence from school, may not be able to drive, difficulty sleeping, fatigue and sleep deprivation are common, if parent overprotective, seeks constant reassurance -Assessment: find level of anxiety at currently, interventions to get them to lower level of anxiety -Useful NANDA Diagnoses: impaired coping skills, ineffective coping o Excessive worry. These people anticipate disaster and are restless, irritable and experience muscle tension. o Decision-making is difficult due to poor concentration and dread of making a mistake. o Common worries: inadequacy in interpersonal relationships, job responsibilities, finances and health of family members. o Sleep disturbances are common because the individual worries about the day's events and real or imagined mistakes, reviews past problems and anticipates future difficulties. o Fatigue is a noticeable of the sleep disturbances. **treated w/ Busbar and/or Cymbalta (SNRI)

Concepts of Major Depressive Disorder

-Experience of great personal pain and suffering (from trauma, neglect, etc) -Common to all ages, races, and both sexes -Vulnerability - related to genetics and life stressors --divorce, trauma, loss of loved one, job, independence etc -persistent depressed mood for min of 2wks

Facts on Aging

-Facts - At least 85% of individuals over 65 have a chronic illness -Individuals age 75 and older are most prone to chronic illnesses and functional disabilities -Age 85 and older - 1 in 3 chance of developing dementia, immobility, incontinence or another age related disability -Women constitute the largest proportion of older adults -With aging - more medical and psychiatric illness

Altered Relationships for bipolar

-Failed relationships -Job loss/ job failure -Need to engage people, then become overbearing -Increased sex drive (could be addiction) -Alienation of others/family (b/c don't believe issue) -Mood lability leads to falling in and out of love -Manipulation of others' self esteem -Ability to find vulnerability in others -Ability to shift responsibility -Limit testing

Therapeutic Treatment Modalities for Child /Adolescent Disorders

-Family therapy -Group therapy -Milieu therapy -Behavior modification: develop behavior plan -Seclusion/restraint: much more guidlines (2hrs for kids but follow institutional policies), locking in seclusion doesn't happen much, kids tend to hurt themselves and do head banging -Time out: more common than seclusion, kid alone but not in locked room -Cognitive-behavioral therapy: continuously used, identifying faulty thinking -Play therapy/drawing/games/storytelling: very specialized levels of treatment -focus on correcting firmly entrenched patters like blaming others and denial of responsibility - provide structures and boundaries -provide activities and goals -establish rapport and promote safety -do not act as authoritarian or argue -CBT helps w/ outburst and aggression -DBT for mindfulness, emotional reg, distress tolerances, personal effectiveness -parent-child interaction therapy (PCIT) -parent management training (PMT) -multi-systemic therapy: 24hrs/day

Nursing Communication Guidelines for Patient with Bipolar Disorder

-Firm, MOF,calm approach -Short, concise statements/explanations -Do not join in joking -Remain neutral; avoid power struggles -Be consistent/firm limit setting -Hear and act on legitimate complaints -Firmly redirect energy into appropriate channels: don't encourage more activity b/c cardiac risk -Reinforcement of reality

Focus on Patient's Coping Skills does what to benefit the pt?

-Focus on Patient's abilities empowers the patient -Increases patient's autonomy and coping skills -Increases independence and increases self-esteem -NO advise giving In think you should try... Why don't you..... **(Disempowering, encourages low self-esteem, increases dependence)

Cultural Aspects

-Focus on culture rather than race. (Each racial group contains multiple ethnic cultures.) -Changing demographics means that mental health nurses will likely be caring for culturally diverse patients. -Self-reflection - Mental health nurses may be grounded in the Western culture. Nurses need to consider their core assumptions and how they affect nursing care.

Nutrition and Sleep Interventions

-Food to eat on the run -High-protein, high-caloric snacks -Daily multivitamins -Weigh regularly -Quiet environment for sleep -Avoid stimulating activities during evening -Reduce or eliminate caffeine intake -Assess sleep-rest patterns: use meds (trazdone, benzos)

Communicating with a patient with psychosis

-For patients with: -Cognitive impairment -Delusions and/or Hallucinations. -Presenting reality -Present what is real (if therapeutic) Pt - "Angels are on the wall and I hear the their voices. -"I do not see angels on the wall or hear voices but -I understand that you do." -Do not argue -Listen Voicing doubt 'Oh really."

Bipolar Disorder

-Formerly called manic-depressive illness -Characterized by two opposite poles, depression and mania --mania: intense mood disturbance, w/ persistent elevation and mood expressiveness, irritability, very extreme --lot of goal directed activity, energy, impulsive -Chronic, recurring, can be life threatening --Individuals can experience interpersonal, occupational difficulties, even during remission --highest lifetime suicide rate among psychiatric disorders

Antianxiety and Short-Acting Sedative Hypnotic Drugs

-GABA calms CNS -benzos increase GABA -cause sedation, hypnotic (sleep-inducing) -used for alcohol w/drawal -do not use w/ alcohol or other CNS depressants SE: if used w/ CNS depressants = RR depression --inhibits motor ability, attention, and judgement --ataxia common in older adults and contribs to falls -only use short term, tolerance and dependence Benzodiazepines -Diazepam ( Valium) -Clonazepam (Klonopin) -Alprazolam (Xanax) -Lorazepam (Ativan) Buspirone (Buspar): decreases anxiety w/out sedative effects or addiction Treatment of Insomnia -Zolpidem (Ambien): give lower doses w/ woman -Temazepam (Restoril) -Eszopicolne (Lunesta): longest 1/2 life (7-8hrs), bitter taste -Trazodone HCL (Desyrel) -sedative effects, selective GABA receptor -SE: amnesia and ataxia -faster onset than benzos

Risk Factors

-Genetics -Neurobiological -Brain Structure Abnormalities -Psychological and Environmental Factors

Biological Theories for depression

-Genetics (Twin and adoptive studies) -Biochemical factors: multiple neurotransmitters (NT) -Neuroendocrine factors: estrogen can increase -Hyperactivity of hypothalamic-pituitary adrenal cortex axis -Increased cortisol secretion= increase for depression -Ventricle enlargement, cortical atrophy, sulcal widening -Inflammation: increased inflam contributes, why fish oil works well -increased risk if first degree relative -neurosis **diathesis-stress model: could have genetic predisposition but have good coping skills

Theories and Risk factors for bipolar

-Genetics: 15-30% greater risk if parent has dx -Neurobiological factors - hypothalamic-pituitary-thyroid-adrenal axis dysfunction --inflam has huge role, if thyroid issue refer to endocrinology -Cultural consideration-some evidence that individuals with higher IQ are affected at greater rates. --challenge and question treatment, difficult -Children with genetic predisposition and increased stressful family life/trauma have an increased risk. -Neurotransmitter receptor site insensitivity-likely there are enough of needed neurotransmitters but they are unable to find their way to receptor sites. -giving birth can trigger -usually have higher IQ's -decreased frontal lobe: lower decision capacity -dysfunction in hippo campus, associated w/ memory -thyroid issues

Giving Approval

-Giving approval - nontherapeutic -Tendency of nurse to reward patient with his/her approval -You did a great job! -Best approach: Ask the patient on how he or she did? Allow the patient to approve self -How do you think you did with this procedure? -pt ends up doing good behavior for other person not for self

Working phase - implementation

-Goal setting -What changes would you like to see happen? -How do you think you can go about this? -What steps can you take? -What can you do today? **practice coping behaviors, establish goals short-term/long-term goals, understand physical and mental abilities of pt for treatment

Silence

-Good if serves a function -Gives patient time to think --especially w/ psychosis or depression -Children and adolescents tend to be uncomfortable with silence. -not absence of communication but didn't way to do so -needs to serve function and is not scary to pt -not always therapeutic for some pts

What is the HEADS SS pscyhosocial interview technique?

-H: home environment (e.g. relations w/ parent and siblings) -E: Education and employment (school performance) -A: Activities (e.g. sports participation, after-school activities, peer relations) -D: Drug, alcohol, or tobacco use -S: sexuality (whether the pt is sexually active, safe sex, contraceptives) -S: suicide risk or symptoms of depression or other mental disorder -S: Safety (how safe does the pat feel at home and school, wear a safety belt, or engage in dangerous or risk activities)

Alcohol Induced Persisting Amnesic Disorders

-Heavy drinking for many years - short term memory loss -Wernicke's encephalopathy - confusion caused by thiamine deficiency - in brain stem - most common in alcoholics, can progress to Korsakoffs -Korsakoff's psychosis -"organic mental disorder with memory loss related to chronic and excessive alcohol use." only 20% recovery rate -Cause of both - thiamine deficiency - poor nutrition associated with alcohol use -s/x: altered gait, confusion, ocular motility (nystagmus, lateral orbital palsy, gaze plasy), aniscoira (unequal pupil size) -responds rapidly to IV thiamine 2-3x/day for 3-12wks

Qualities of Therapeutic Use of Self needed for good relationship

-Honesty -Respect or positive regard -Genuineness -Confidentiality -Empathy -Warmth: self evident, part of empathy -Nonjudgmental -Acceptance -Availability: pt often dependent -Active Listening: no charting -Hope: focus on strengths, no false reassurance -Accountability: do self reflection **need to understand own values and beliefs --values: abstract standards that are ideal, + or -

Outcome criteria

-Hoped for outcomes of maximum level the patient can achieve through nursing interven. -reflect desired change -use NOC to evaluate interventions --each outcomes has group of indicators to determine pt status in relation to the outcome -all outcomes are written in positive terms ex: -The patient will......Measurable behaviors..........by when.......... -The patient will remain free from injury during hospital stay

On the continuum of care for schizo pts, what types of facilities can they use for treatment?

-Hospitalization: acute phase -Day hospitalization -Day treatment -Supportive housing **pt need meds, adherence, trust w/ providers, and community-based services for stabilization and maintenance

Cluster C: Avoidant Personality Disorders

-Hypersensitive to criticism/rejection -Self-imposed social isolation, even social media -Preoccupied with being criticized/rejected -Strongly wants relationship but shies away -Avoids occupation involving interpersonal contact -Views self as socially inept, inferiors -shyness increases w/ age

Populations at Risk for Inadequate Cultural Care

-Immigrants -Refugees -Cultural minorities

Symptoms - Hypomanic Episode for bipolar

-Impairment less severe than manic (lower risk) -Length of episode - at least 4 days duration -Not severe enough to warrant hospitalization -Persistent elevated expansive or irritable mood -Plus three of the following: --Increased self esteem or grandiosity --Decreased need for sleep --Easily distracted --Increased goal-directed activity **less psychosis and impulsitivity than hyper-

Shortage of psychiatrists worldwide

-In 2014, 45% of the world's population lived in a country where there was less than 1 psychiatrist to serve 100,000 people. -The US has the highest number of psychiatrists per capita in the world - 16 psychiatrists per 100,000 --Europe - 10 psychiatrists per 100,000 -Underdeveloped countries - -Cambodia - 50 psychiatrists for 10 million people -Summation: Great need for mental health services in the world, and with the increase of natural disasters, more people are in crisis. -Increased need for Advanced Practice Psychiatric -Nurses -Masters Degree in Psychiatric mental health nursing - get prescriptive authority

Dissociative Amnesia

-Inability to recall personal info often occurring after traumatic event -may be able to remember all events up to certain point Types of amnesia -Generalized: inability to recall entire lifetime -Localized: inability to remember all events in certain periods -Selective: some but not all events recalled

Sedative/Hypnotic and Antianxiety Medication Withdrawal

-Include Benzodiazepines, barbiturate hypnotics -CNS depressants - dangerous withdrawal - seizures -Same withdrawal effects as alcohol - opposite of the drug -Rebound effect -Agitation, hyperactivity, tremors, insomnia, anxiety grand mal seizures -When withdrawal occurs depends on the half-life of the drug -Overdose - gastric lavage - sometimes in ICU -Treatment - gradual reduction of benzodiazepines will prevent seizures

Summary

-Individuals suffering from physical or mental illness are challenged to cope and find meaning. -Nurses are in a position to assist the patients, sometime on a 24 hour basis, when a spiritual need arises. -Nurses have the responsibility to provide holistic care, mind, body and spirit. -Nurses can provide a "presence" and a "safe place" for patients to discuss spiritual issues related often to their illness and suffering. -Nurses are to compassionate, caring and respectful in spiritual care.

Cluster B: Narcissistic Personality Disorder

-Inflated sense of self-importance -Constant attention-grabbing behavior -Manipulation of others -No regard for feeling of others, not criminalistic aspect of behavior -Arrogant manner toward others -Unreasonable expectation for special treatment -Often envious of others with belief that others are envious of him/her -lack empathy causes issues in relationships -personality trait of antagonism, shown by grandiosity and attention-seeking -pts don't often believe they are narcissistic

Clinical picture

-Inflexible, maladaptive responses to stress -Disability in working and loving/relationships can be struggle -Avoidance and fear of rejection, have significant fear, become people pleasers or avoid others -Blurred boundaries between self and other, overly friendly, can see you as friend instead of caregiver -Insensitivity to needs of others -Demanding and fault finding: espcecially as provider and find fault in themselves, don't allow expression of that fault -Lack of accountability -Evoke intense interpersonal conflict: may have to rotate staff more frequently to help w/ inflexibility

Multidisciplinary Team: Physicians, Nurses, Dieticians, Group Therapists, Social workers

-Inpatient - talk therapy, groups, medication management, crisis intervention. -Outpatient -Therapist - advance practice nurse, psychiatrist, social worker, psychologist -Use various theoretical models -Cognitive/behavioral -Dialectal -Others

Aggressive Situations in General Hospital Settings

-Inpatients with healthy coping, but feeling overwhelmed -Patients with marginal coping skills: give distractions, make them feel heard, give gentle challenges -Violence in inpatient psychiatric settings --based on stimulation -De-escalation techniques: all units need to know -Debriefing -Documentation: all information

Assessment Guidelines: Sexual Assault Victim

-Institutional protocol for evidence collection (rape kits) -sexual assault nursing very specific kind of nursing, able to collect specimens and counsel pt --assault vic consider high priority -Consent forms (right to refuse treatment) -Specific guidelines are followed -Documentation -Physical trauma: doc -Psychological reactions: doc -Survivor's support system: assess -Nurse's self assessment: any past assault, need to separate own feelings to care for pt -assess level of anxiety, coping mechanisms, available support systems, s/x of psychical trauma, information obtained from the assessment is analyzed and nursing diagnosis formulated

define moral behavior and values

-Moral behavior -"conduct that results in serious critical thinking on how to treat others based on ethical principles" (Butts and Rich) -Values - "important beliefs about what is desirable"

What are the Current and future issues for PMHN?

-Insurance coverage: w/ lack of coverage pts have shorter stay times, nurse needs to be more skilled at discharge preparation b/c lack of time -An aging population: care for dementia -Cultural diversity: practice needs to meet needs of culture and beliefs -Genetic mapping: can see if you have genetic disposition to mental illness, creates problems about who can get this info, etc -Violence: mentally ill often victims of violence, ZODGG :silent no more campaign, nurses often victims of workplace violence

Initial phase of Clinical Interview

-Introduction --set pace --ask how they'd like to be addressed -Setting --pt must feel safe -Confidentiality --what's shared and not shared -Establishing rapport

Orientation Phase

-Introduction -Confidentiality -Establishing Rapport -can last a few meetings or longer period -pt can express thoughts and feelings, identify problems, and discuss realistic goals -in intro establish rapport, specify a contract (meeting times, goals, boundaries), explain confidentiality (what info will.will not be shared)

Violation by Crime

-Involve emotional violation and trauma -Result: loss of trust; loss of sense of control -Emotional reactions to crime --Denial, fear, anger, powerlessness --Depression, sense of failure, guilt -Disrupted family relationships

Termination of Clinical Interview

-Is there anything else you would like to talk about -Summary -Goal setting -debriefing: critical convo and reflection regarding experience that results in growth and learning

Ethical Theoretical Perspectives & Principles

-Kantianism - what is the motivation on what the action is based on (Immanuel Kant, Philosopher) -Utilitarianism - whatever promotes happiness -Christian Ethics - focused on the way and life of Jesus Christ - love, forgiveness honesty -Natural Law - decisions vs right and wrong are self-evident and determined by human nature

What are 3 common Ethical Issues in Mental Health?

-Labeling -Stigma -Boundaries

Treatment for Depression: Antidepressant Medications

-Lag time before symptoms improve -Monitor for increased suicidal tendencies -Cheeking and hoarding -Vital signs -Signs of early toxicity -Sexual side effects of SSRI's -Drug-drug and drug-food interactions -Treatment Strategies: --First -line agents: SSRI's

Legal and Ethical Issues with Those of Limited Capacity

-Legal and ethical are connected -Laws (legal) reflect ethical values of society -The nurse needs to follow the law. -Mental health laws (statutes) vary from state to state -Issues: -Limited decision making capacity -Abuse -Neglect -Elder mistreatment

SSRI-Drug Interactions

-MAOI's -Lithium -Antipsychotics -Benzodiazepines -TCA's -Anticonvulsants

Reflecting

-Making patient aware of inner thoughts and feelings -Nurse: "You sound as if you have many disappointments." -Patient: "What do you think I should do in this situation?" -Nurse - reflecting back - "What do you think?"

Things to remember for bipolar

-Mania can be manipulative be consistent and MOF with communication -Medications cause challenging side effects, this is often the reason for discontinuation -Patients typically enjoy the hypomanic phase as they are very self directed -Cardiac complications can occur during the manic phase -Patient and family education is necessary in treatment -Early detection and treatment could diminish substance abuse and suicide attempts.

Nursing Process: Evaluation, Personality Disorders

-May be difficult because patient may not remain in treatment long enough to see results --could see in outpt --inpt: stablize and not let them be bothersome to other pts and staff, give them idea that there is hope -Specific, short-term outcomes may be accomplished -Patient can be given the message of hope that quality of life can always be improved

Advanced Practice interventions

-Med prescription and treatment -psychotherapy -consultation **masters or DNP --no diff between NP or clinical nurse specialist w/ prescriptive authority

Right to Treatment

-Medical and psychiatric care and treatment be provided to all persons admitted to a public hospital -right to privacy and dignity -right to least restrictive environment -right to attorney, celery, and private care providers -Treatment must meet the following criteria ... 1. Humane environment 2. Qualified and sufficient staff to provide adequate treatment 3. Individualized plan of care

Nursing Process: Assessment for schizo

-Medical workup: eliminate any other reasons for psychosis -Assess for command hallucinations: voices telling pt to hurt self or others -Suicide risk -Determine patient's belief system: do they believe have illness, religiously preoccupied -Co-morbidity: med or substance -Medication use/compliance -Family response: involved fam? -Social support

Types of Problematic Drinking

-Men - no more than 14 drinks a week or up to two drinks/day -Women - no more than 7 drinks a week or one drink a day -Elderly - no more than 7 drinks a week -Minors or pregnant women should not drink. Binge drinking - drink too much too quickly -Women - four or more drinks within 2 hours -Men - five or more drinks within 2 hour Heavy drinking - drinking too much too often -Women - 8 or more drinks in a week -Men - more than 14 drinks a week

Mental Health Assessment of Children

-Methods of data collections: include all contact, counselors, social media(look at it w/ pt), friends, case managers, involve parents, involve CPS if needed -use games, drawings, puppets, etc Mental status assessment --What therapeutic communication techniques are different in kids? (13 and below have concrete thinking so yes or no questions and play therapy, older than 13 use adult-like language and behaviors) --How do you need to adjust your language to ensure kids understand you? (do a lot of clarifying and communicating with them at their level) Developmental assessment --Ericksons Stages of Development: see where they're at and where they need to be

Adjustment Disorder

-Mild version of ASD and PTSD -Onset is after stressful events; breakup, chronic illness, loss of job, retirement... -The event is typically not traumatic in nature, not caused by trauma -Sx vary, often treated with antidepressants **very common reason pts seek treatment

Delirium Assessment: moods/behavior

-Mood - may swing to - fear, anxiety, anger, euphoria, depression -Behavior -erratic - motor restlessness, agitation, hyperactive or hypoactive

Electroconvulsive Therapy (ECT)

-Most effective Treatment for acute depression -Contraindicated: Recent MI, CHF, Brain Tumors, Sub-dural hematoma -Used mainly in drug resistant patients or patients with catanoia/Schizophrenia --can be used in pregnancy, better than meds -induces brief sz lasting 30-60sec -completed in surgery suite w/ anesthesiologist present -2-3 treatments/wk for total of 6-12 treatments, can go 1-2x/month for maintanence -have a lot of short term memory loss, including loss of memory of treatment of self

Narrative vs Problem-oriented charting

-Narrative: descriptive, written in chronological order --benefits: addresses any behavior, explains flow-sheets, multidisciplinary use, expressive --cons: unstructured, diff organization, leads to omission, can include unnecessary info -Problem-oriented: SOAPIE S: subjective O: objective A: assessment P: Plan I: Implementation E: Evaluation --benefits: structured, consistent organization, all elements of nursing process, easy retrieval of info, less unnecessary info, multidisciplinary ease --cons: time and effort to structure info, limits entry info, could result in loss of data, not chronological, carries neg connotation

Unintentional Torts

-Negligence -Breach of Duty -Standards of Nursing Care -Documentation -Negligence (or malpractice): failure to use ordinary care in any professional or personal situation when you have a duty to do so --failure to act according to professional standards -Breach of duty: not performing the standard of care that other nurses would be expected to perform

Neurobiology of Alzheimer's

-Neurotransmitters implicated in Alzheimer's - acetycholine and glutamate Acetycholline - --Is involved in learning memory and mood decreases in Alzheimer's- --Glutamate - allows calcium to enter cell - in -Alzheimer's there is excess glutamate and therefore overexposure to calcium

Nicotine

-Nicotine -Acute effects: increased BP and HR -Chronic diseases: lung diseases, cardiovascular diseases and cancers, adverse preg outcomes -Treatment: Nicotine Replacement Therapy, (varenicline (Chantix); clonidine (Catapres) CBT, support programs -w/drawal: WG of 4-7lbs, HR decreases by 12 beats/min, restlessness, insomnia, diff concentration, depression, irritability

Etiologic Theories Related to Somatoform Disorders

-No direct evidence for genetic etiology -Some data support that somatization disorder runs in families -Genetic factors may play role in predisposition to somatoform disorders -Learning theories and sociocultural factors -Psychodynamic theory -Interpersonal theory -Cultural considerations

Nonbenzodiazepine: Buspirone (Buspar)

-Nonsedating, non-habit forming -No highs - decrease abuse potential -No cross tolerance with alcohol, sedatives -Takes 1 to 6 weeks for full effect -No dependence, withdrawal, tolerance -Divided doses -Take with food -Few drug-drug interactions

Benzodiazepines: Patient Teaching

-Not for minor stresses -OTC drugs might enhance action -Kava-kava and valerian cause additive effect -Avoid driving until tolerance develops -Do not exceed prescribed dose, don't use anyone elses meds -Avoid alcohol and CNS depressants -Do not stop abruptly: will go through w/drawl, looks very sim to alcohol w/drawl

Veracity

-Nurse's duty to communicate truthfully -Franciscan values- dignity of the individual, peace and justice, stewardship, reconciliation Example: -Observing and relating facts -Factual and thorough documentation -Standing up for what's right and reporting another nurse who is not meeting standards of care -Telling the patient the truth and not misleading him or her. This can be done with tact and good -judgment

Giving disapproval

-Nurse: "You are acting like a child." -Judgmental - causes the patient to be angry and defensive -Best - State behavior by giving an observation: I noticed in group that you became angry, tell me more about that? OR -Best - That behavior is not acceptable on this unit. Focus on the behavior - not the person. Setting limits

Dissociative Disorders 1

-Occur after significant traumas -Unconscious defense mechanism that protects the individual from emotional distress (childhood abuse) -Positive sx: Flashbacks, triggers (smells, food, music, etc) -Negative sx: lack of sense of body parts, decline in memory -Involuntary response that protects the individual from full awareness of the trauma -disturbances memory, consciousness, self-identity, and perception --still have intake reality testing, but on autopilot

Acute Stress Disorder

-Occurs within 1 month after exposure to highly traumatic event -lasts 3 days but not more than a month, if longer than 1 month then PTSD -Characterized by at least 3 dissociative symptoms during/after event --Subjective sense of numbing --Reduction in awareness of surroundings --Derealization --Depersonalization --Dissociative amnesia -debriefing occurs w/ing 12-48hrs of even (hasn't shown to help) -CBT and EMDR can help

Mild Cognitive Impairment- Causes

-Often stems for diseases or treatment of diseases -Stroke or other vascular disease traumatic brain injury -a medication side effect -an underlying health problem such as sleep deprivation, depression or anxiety -Degenerative brain disease (Alzheimer's) MCI is a precursor

My Visit to Malawi, Africa

-One nurse running unit - prescribing medications -she was visited periodically by a mental health supervisor -Extreme shortage of psychiatrists in Africa -Use of traditional antipsychotics because of cost -Clean but very poor facilities

Anxiety

-One of the most basic human emotions that results from real or perceived threats -Normal anxiety is healthy and necessary for survival. -Anxiety provides the energy we need to carry out tasks and motivates us to survive change. --prob is when turns to mod-sev -pts have rigid, repetitive, ineffective behaviors to try to control ansiety

What are some Therapeutic Techniques?

-Open ended questions -Focused - questions/statements -Closed Ended questions -Projective questions -Silence -Active Listening -clarifying techniques

Autonomy

-Respecting rights of others to make own decisions (Franciscan value of dignity of the individual) -Examples: -Asking pt about his or her goals -Allowing the patient to participate in care as much as possible -In problem solving, asking patients what would work for them -Opposite: nurses are intrusive and command the patient to take a shower at this time. -Giving the patient advice on what he/she should or shouldn't do. This is different than patient education

Opioid Use Disorder - Symptoms of Withdrawal, Intoxication, Overdose

-Opioid Intoxication - physical (constricted pupils, decreased respiration, drowsiness, decreased BP, slurred speech, psychomotor retardation, decreased memory, intense drowsiness can lead to coma; -Psychological-perceptual - euphoria followed by dysphoria; impairment of attention, judgment, and memory -Opioid Withdrawal - flu-like symptoms (runny nose, cramps, N & V, Muscle aches, chills, diaphoresis, fever, diarrhea) yawning, Insomnia, irritability, Panic, & Lacrimation - very unpleasant -males: spontaneous ejaculation and sweating -starts 6-12hrs after use, lasts 5 days -occurs w/ reduction of heavy use or opioid antagonist as well -Opioid Overdose - Triad symptoms (coma, respiratory depression/arrest (usually cause of death), pinpoint pupils, possible dilation of pupils as a result of anoxia, cardiac arrest and death, shock, convulsions and death

Opioid Use Disorder - Drugs, Criteria, Signs and Symptoms

-Opioids: morphine, heroin, codeine, oxycodone -Bought illegally or prescribed - designed for short term use -DSM V criteria - "preoccupation with a desire to obtain and take opioids, as well as using more than intended despite social and professional consequences due to these behaviors." -Signs and Symptoms: Drug seeking behavior, legal & social ramifications, medical complications, cravings, & withdrawal symptoms -increase tolerance w/ use

Outcomes for Schizo

-Outcome identification: dependent on phase of illness -Overall goal: least sympt as possible, maintian meds, higher quality of life -Other goals: low aggression, orient back to reality if paranoid

Nursing Process: Diagnosis and Outcome Identification

-Outcome identification: include specific goals for patient safety and related to vegetative/physical signs of depression -point out normal observation for w/drawn pt, helps pt identify reality b/c they're not ready to talk, want to be simple b/c they're thought process slow --pay attention to suicidal ideation "not worth it"

Outcome Identification:Delirium

-Outcomes will be related to the nursing diagnosis -Example outcomes: -The patient will remain safe and free from injury while in the hospital -Patient will remain free from falls and injuries while confused with the aid of nursing safety measures throughout hospital stay.

Communication and Health Teaching

-Paranoid patient: orient back to reality, can make then aggressive, be matter of fact -Hallucinating/delusional patient -Loose associations: somewhat able to follow a thought process if it's loosely associated -Include patient and family in teaching: talk a lot about prevention, sleeping, nutrition, etc, all ways to prevent psychotic episodes -Topics to include in health teaching

Concepts of the Nurse Patient Relationship

-Patient Centered Care -Therapeutic Use of Self -Importance of Talk Therapy

Patient in Seclusion and restraints

-Patient checked q 15 minutes for comfort - check extremities - patient's needs for food, hydration and toileting -Detailed documentation - subjective and objective data --Behavior leading to seclusion or restraint --Charting q 15 minutes --Time placed and released

Nursing Process: Assessment for bipolar

-Patient dangerous to self or others -Medical symptoms -Presence of other medical/psychiatric conditions -Hospitalization necessary ? -Pt and family understanding of disorder, treatment, medications, support groups assess: -Mood: its mood disorder, mania (elevated w/ emotions, euphoric), irritable, lot of energy -Behavior (impulsivity) -Thought Process: pressured speech, circumstantial, tangetial, loose associations, flight of ideas, clang association -Thought Content: grandiose, persecutory delusions -Speech Pattern -Cognitive Function

Documentation

-Patient status during shift -Written in chronological order -Significant symptoms, behaviors and events -Supported by subjective and objective data patient stated ..... -used non-adherent instead of non-compliant, doesn't label patient negatively -need to document more information than just to word to protect self -Narrative vs Problem-oriented charting, Legal Considerations for Documentation of Care **7th step in nursing process

Right to Refuse Treatment

-Patients have the right to receive treatment and the right to refuse it -Patients may withhold/withdraw consent at any time even if under invol. committment -Retraction of verbal or written consent previously given must be honored

What should the nurse do if a patient refuses medication?

-People who have been committed retain their right to refuse treatment -In an emergency to prevent a person from causing serious harm to self/others, a person may be medicated without a court hearing -Following a court hearing a person can be medicated if all of the following are met 1. Has a serious mental illness 2. Ability to function is deteriorating or is suffering/exhibiting threatening behavior 3. Benefits of treatment outweigh harm 4. Person lacks capacity to make reasoned decision about treatment 5. Less restrictive services have been found inappropriate * Medication can be considered a chemical restraint

Common Stigmatizing Beliefs about Mental Illness

-People with mental illness are dangerous to others. -Mental illness is feigned or imaginary. -Mental illness reflects a weakness of character -Disorders are self-inflicted. -outcome is poor. -Disorders are incurable. -difficult to communicate with people who have mental illness

Levels of anxiety

-Peplau's Anxiety Model (1968) -Mild Anxiety: necessary to perceive, hear, and grasp more information. Sx: slight discomfort, restlessness, irritability, mild psychomotor agitation (fidgeting, foot tapping...) --helps brain to remember and retain info -Moderate Anxiety: sees, hears, and grasps less information and exhibits selective inattention. -Ability to think is impaired but learning can occur. -Sx: tension, physical sx, somatic sx, HR increases, stomach pain, sweating -Severe anxiety: unable to focus on details and level of perception has lowered. Unable to learn or problem solve. Sx; lots of somatic sx, physical sx, fear of doom/death., sweating, discomfort, voice changes, periods of hyperventilation -Panic: inability to process, possibly losing touch with reality. Sx; overly calm appearing/withdrwan or the opposite, hallucinations, erratic physical sx --pacing, running, shooting, screaming, impulsive, can't reduce their own anxiety, can lead to exhaustion, can appear quit when it does occur but dramatic to person its happening to

CBT

-helps reduce and cope w/ symptoms like delusions and impaired social function -focus on patterns of thinking and self-talk -guides pts away from neg talk to more effective thinking -uses positive reinforcers -CET: principle of neuroplasticity, computer based, lengthy, help interprets social and emotional info

Asian Culture

-Per Asian culture, women have more mental disorders -Asian women in US have conflict with US roles of women being more independent and self- sufficient contrary to the role of women in their own culture -Asian women are more dependent on men and may ask the husband to make the final decision on her care. -Asian women are at greater risk for suicide than woman of other cultures. Asian culture: -Mental illness caused by lack of harmony with emotions - or by evil spirits -express psychological stress in physical complaints social stigma and "saving face" often prevent -Asians from seeking mental health care,

Vulnerable population: Incarcerated Persons with Mental Illness

-Percentage of inmates with mental illness -64% in the local jail -56% in state prisons -45% in federal prisons Problem - Inadequate funds in State budgets -Mentally ill prone to criminal behavior -Mentally ill with criminal behavior sometimes end up in the prison system -Mentally ill in prison have a right to treatment

Depersonalization Disorder

-Persistent alteration in perception of self with intact reality testing, like watching themselves from outside their body, not always able to understand its happening to them -response to acute stress --Person feels mechanical, dreamy, or detached from body Can be precipitated by: --Severe acute stress --Childhood emotional abuse -derealization: focus on outside world, recurring feeling that one's surroundings are unreal or distant, feels mechanical, dreamy, detached from the body

Specific Phobias

-Persistent fear of a specific thing, activity, or situation that causes the affected person to avoid or eliminate those from their lives. -Often occur due to negative or traumatic feelings/events. -Most likely not hospitalized for phobia but other co-morbid conditions; MDD, anxiety, substance abuse, somatic symptom disorders, dependent personality disorders --typically so specific pt can avoid the phobia, if hospitalized its for something else o A persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance. o Characterized by high levels of anxiety or fear in respond to specific object it situation. (Examples: dogs, spiders, heights, water, blood, closed spaces, tunnels, bridges, etc.) o A phobic person may not be able to think about or visualize the object or situation without being severely anxious. o Prev higher if first degree relative, have comorbs o Fear of pub speaking most common o Risk: childhood mistreatment or adverse evens, shyness that's heritable o Can lead to depression social isolation

What Factors that affect communication?

-Personal -Environmental -Relationship --Complimentary: one person has more control --Symmetrical: friends

Concept of Personality and Personality Disorders

-Personality : Thoughts, patterns, and feelings that experiences or relationships. Thought to unhealthy when relationships are maladaptive -formed very early -Personality traits: characteristics of thoughts, behaviors, and feelings. -Personality disorders: Difficult to treat, deeply ingrained maladaptive pattern of behavior that causes difficulties in relationships and interaction with society. -pts don't want to hear they have this disorder and can feel its the fault of others and not themselves -had maladaptive patterns for yrs

Nursing Process: Planning, Implementation, and Interventions

-Planning: based on level of anxiety, need to lower level -Implementation: based on level, during panic and sev. reorient to reality, tell safe place, stay w/ them -Interventions --Community resources offering specialized treatments --Community support groups --Therapeutic communication, promotion of self-care activities, psychobiological activities, health teaching, and health promotion -use open-ended questions and be specific, closing off communication or bring up irrelevant topics can increase pt anxiety -talk about past coping mechanisms and help consider other activities to temp. relieve inner tension -Milieu therapy: identify anxiety b/f it occurs in pts so not to disrupt milieu or other pts

Nursing Process: Planning and Implementation schizo

-Planning: dependent on particular phase of illness --Acute phase: hospitalization --Maintenance phase: focus on triggers that cause issues (stress, drugs, etc) ---discuss safety and nutrition --Stabilization phase: may need help w/ housing, support system -Implementation: geared toward patient's strengths and healthy functioning as well as weaknesses/symptoms

Planning and Implementation for depression

-Planning: gear towards pts goals, accounts risk for suicide, focus on safety -Implementation -Focus interventions on specific symptoms with priority related to suicide prevention -Teaching pt and family --health promotion: self care -Focus on pre-discharge counseling -depends on phase: --Acute: 6-12wks, hospitalization --Continuation: 4-9 months, education, med adherence --maintenance: 1 or more yrs, prevention of symptoms **focus on w/drawn person most, look for cues

Nursing Process: Planning and Implementation for bipolar

-Planning: related to phase, if manic or depressed at greater risk for hospitalization -Directed toward establishing therapeutic alliance --Acute phase - related to safety in hospital environment, establishment of controls and medical stabilization (cardiac and endocrine stable, need to sleep

Stimulant Use Disorder 2

-Populations using - long distance truckers, students studying for exams, soldiers in wartime and athletes -Increased use, craving, tolerance -Physical symptoms except for cocaine -Two or more of the following: chest pain, cardiac arrhythmias, high or low blood pressure, tachycardia or bradycardia, respiratory depression, dilated pupils, perspiration, chills, nausea or vomiting, weight loss psychomotor agitation or retardation, weakness, confusion, seizures or coma

Help for Survivors of Suicide

-Postvention for survivors initiated 24-72 hours after death (risk for death) -Survivors - feel "going crazy" --Need to know feelings are normal -Anger toward suicide victim -PTSD - common to survivors --Self help groups and counseling

Psychosocial Nursing Diagnoses of the Older Adult

-Powerlessness -Anxiety -Fear -Ineffective coping -Grieving -Complicated Grieving -Compromised Family coping -Caregiver role strain -Impaired social interaction **Develop and individualized plan of care

Problems -patient with Dementia

-Practical explanation of problems that may occur with the patient along with examples -Affect caregivers and families -Family needs help/support - outside resources -disorientation, need physcial help, risk in home, risk outside home, apathy, poor communication, repetiviveness, uncontrolled emotion or behavior, incontinence, emotinal reactions, mistaken beliefs, decision making, burden on family

Cluster C: Obsessive-Compulsive Personality Disorder

-Preoccupied with details, rules, lists -Perfectionist, stubbornness, indecisiveness, limited emotional expressiveness -Unable to share responsibility with others -Devoted to work, exclusion of pleasurable activities -Financial stinginess or cheap -Inability to discard useless objects, hoard b/c feel emotional connection w/ them -Discomfort with emotions and relationships person, anything they can't control -have relationships (and feel genuine emotion) but disregard to get to goals, becomes too hyper-focused, loses ability to complete tasks -more men, older sibs, first degree relative, harsh upbringing, relatively common **OC personality is more focused on perfection, less compulsions

Other Therapeutic Techniques

-Presenting reality -Voicing doubt -Giving information -Seeking information -Summarizing -Encourage formulation of a plan -giving recognition -offering general leads -giving broad openings -placing events in sequence -making observations -encouraging description and comparison -giving info -voicing doubt -seeking consensual validation -encouraging evaluation -suggesting collaboration -summarizing

Prevalence and Comorbidity for Major Depressive Disorder

-Prevalence --Leading cause of disability in US --Lifetime prevalence of major depressive episode: 8.6% --More common in women (b/c they seek treatment more) -Co-morbidity --Frequent with other psychiatric disorders --Increases with presence of medical disorders (at greater risk if chronic conditions)

What is part of the psychosocial status assessment?

-Previous hospitalization -education -occupation -social patterns -sexual patterns -interests and abilities -substance use and abuse -coping abilities -spiritual assessment -gathers subjective data -start w/ asking why treatment is necessary

OUTPATIENT MENTAL HEALTH CARE providers?

-Primary care providers: docs, neuro docs -Specialty psychiatric care providers -Patient-centered health/medical homes: pt goes for all needs not just mental health -Community clinics: under or uninsured -Psychiatric home care: need help w/ meds/injectables -Assertive community treatment (ACT): 10% highest users of services need higher level of treatment, gives wrap around services, meds, shopping, etc -Partial hospitalization programs (PHPs): 3-5hrs outpt groups (can go home) -Intensive outpatient programs (IOPs): (3hrs 3-5x/wk) -Other outpatient venues for psychiatric care --Telephone crisis counseling --Telephone outreach --Internet --Telemental health --biopsychosocial case management: asses to treatment

Prevention of Abuse

-Primary prevention: id caregiver stress, reduce stress, reduce risk factors, ensure caregivers are getting social and medical support and rest, make sure pt is communicating, coping skills, increase social support and self-esteem -Secondary prevention: screening programs for early intervention in abusive situations to minimize disabling or long-term effects, getting pt and caregiver on meds, reduce caregiver stress, case-management services, counseling, education, helping set up respite or housekeeping -Tertiary prevention: occurs in mental health care settings --involves nurses facilitate healing and rehabilitation process by counseling individuals and families, providing support for survivors, and assist survivors to obtain safety, health, and well-being --legal advocacy available -psychotherapy often indicated for perpetrators -family and group psychotherapy available as well

Planning during nursing assessment

-Principles in planning: -Safety -Compatible and appropriate -Realistic and individualized -Evidenced-based -identify safe, pertinent, evidence-based actions -strive to use interventions that are culturally relevant and compatible w/ health beliefs and practices -document plan using recognized terminology

Nursing process - Alcohol Use Disorder

-Priority nursing diagnosis should address safety: -Risk for injury related to alcohol withdrawal -Ineffective coping related to alcohol use as evidenced by increased alcohol use and impairment of life functioning. -use motivational interviewing -assess what stage their at in determining quiting readiness

Nursing Diagnosis

-Problem -Related factors -Defining characteristics: s/x Types of Nursing Diagnoses -Actual -Health promoting: not related to factors -Risk Diagnoses: not define. characteristics -Related factors: used w/ problem-focused diagnosis, its what needs to be changed

Phases of Schizophrenia

-Prodromal -Acute -Stabilization -Maintenance or Residual oPrognostic Considerations: if can stop pt from having a second psychotic break, can prevent further brain damage w/ worsening symptoms oProdromal: mild changes in thinking, not enough to met criteria for full diagnosis of schizo, deterioration of concentration --pt odd, eccentric, called out as weird or strange, early diagnosis is key oAcute: vary, when psychosis starts: hallucinations, delusion, impaired/disorganized thinking --as they worsen they have difficulty coping and try to conceal symptoms, but as sympts are more readily occurring, harder to conceal, where hospitalization occurs oStabilization: symptoms are stabilizing, pt in outpt care w/ treatment, may have inpt treatment --not every pt requires intensive care oMaintenance or Residual: during this phase the positive or psychotic symptoms have diminished but neg and cog symptoms still present, makes difficult for pt to live on their own --pts often have recurrent, worsening of symptoms and episodes --some have episodes that don't get better and have increased impairment in their symptoms

Peplau's View of the Nurse's Role

-Professional -Collaborator -Advocate -Facilitator -Promoter of the Patient's Autonomy

What's the purpose of the nursing process?

-Provides framework for identifying appropriate nursing interventions -Nursing diagnosis is a clinical judgment about actual or potential responses to health problems -used to assess and diagnose pts illness, outcomes, plan, implement and evaluate

CONTINUUM OF CARE function?

-Provides patients w/ wide range of treatment options --total freedom to total hospitalization -Facilitates effective/appropriate care -Standardized decision-making process: tailored to individual but certain pre-made plans for certain illnesses -least restrictive setting is goal --if pt doesn't require inpt then make sure they're in outpt, no restraints unless necessary

Treatment for Personality Disorders: Psychotherapy

-Psychodynamic psychotherapy -Cognitive-behavioral therapy -Dialectical behavior therapy (DBT)(borderline personality disorders go to) --Developed by Marsha Linehan (1993) for patients with borderline personality disorder --Focus on stabilizing patient and achieving behavioral control

Nursing: Implementation and Evaluation

-Psychosocial: develop rapport(paplaues therory), learn verbal and non-verbal interventions, allow space, maintain calmness-be aware of your internal anxieties/fear, stay out of striking distance and keep pts out of striking distance -pt is not able to learn new things when angry -need to slow voice down, do not yell -being a role model and teaching is not during aggression -Pharmacological prn medications; Haldol, Ativan --Long term medications: beta blockers, ssris, antipsychotics -Role model and educator -Milieu manager --Restraints and seclusion -are staff safe? wearing things that could be pull or pt could choke staff -look at environment, don't stand directly in door -provide lots of feedback, say looking angry whats going on -avoid confrontation and help pts on unit not to engage w/ angry pt -consider medication management -Post-assaultive stage interventions -pre as well -practice deescalation principals, 509 -know policy -seclusion is only if door is locked --not always an options b/c pt could cause harm -restraint is manual way of holding back pt, need order from health car provider -pt needs close monitoring, video or 1-on-1 monitoring -help pt where things went wrong, why they're in restraints -check every 15 mins, vitals, ROM, able to use bathroom -avoid restraints at all costs, has been death, if chronic medical or mental health illness at greater risk for harm -post: did we escalate or deescalate, need more education or not, if injury occurred need documentation properly and reported, nurse also needs to report (very under reported) -Evaluation

Clarifying Techniques

-Purpose - nurse understanding the accuracy of the patient's statements --paraphrasing --restating --relfecting --exploring Seeking Clarification- -I am not sure I follow you. -What was the main point of what you said? -Paraphrasing - restating the content in fewer words -You seem to be saying......

PSYCHIATRIC/MENTAL HEALTH NURSING: What does a PMHN do?

-Purposeful use of self --Goal-directed and planned -Identify & treat problems/responses to illness -Assess & develop holistic plan of care that is grounded in theory & based on sound research evidence -promote mental health through assessment, diagnosis, and treatment of mental health problems and psychiatric disorders

Older Abuse and Legal Aspects

-Rapidly growing problem -Estimated 1 out of every 20 older Americans -Types of elder abuse -Elder abuse prevention laws and reporting systems -Adult Protective Services (APS)

Posttraumatic Stress Disorder (PTSD) and Nursing Interventions

-Re-experiencing highly traumatic event -Characterized by: --Recurrent dreams or flashbacks (dissociate experiences in which event is relived) --Avoidance of stimuli associated with trauma --Numbing of responsiveness: may not be able to speak during trigger --Persistent symptoms of increased arousal -nightmares/terrors, hallucinations, intrusive traumatic thoughts and memories, re-experiencing or flashbacks of trauma, reenactments in play, self-injurious behaviors -irritability, avoidance, anger, self-risk behavior, aggressive, dissociate **need to assess for suicidal or violent behavior -SSRI's like zoloft or paxil -Nardil (MAOIs), Effexor (SNRI), Remeron (TCA's) -Propranolol (inderal) beta-blocker **Ecstasy getting approved

Preorientation Phase

-Reading the chart -Getting staff report -Discussion with instructor **look at meds, progress notes, research pt, analyze own feelings

Alcohol - interferes with sleep

-Reduces REM sleep -Alcohol initially sedates tissue - then agitates. -May wake up in the middle of the night -Less stage four sleep - sleep fragmentation -"the excitatory neurotransmitter glutamate increases as the initial depressant effect of alcohol wanes thereby causing irritability and inability to sleep"

Alcohol Withdrawal

-Reducing or quitting alcohol after heavy and prolonged use Assessment - -Initial signs - Increased vital signs - BP and P tremulousness (shakes, jitters) - 6-8 hours after alcohol cessation (use Librium for tremors) -Agitation, lack of appetite, nausea, vomiting, insomnia, impaired cognition and mild perceptual change -if pt undergoing psychosis then med emergency=risk of sz, LOC, delirium --can happen 8-10hrs after quitting --give ativan or Librim (PO or IM) -GOAL - prevent alcohol withdrawal - treat the symptoms -GOOD ASSESSMENT - Patient may have these symptoms on a medical surgical unit

Lithium Carbonate Adverse reactions

-Related to lithium toxicity- fine line between therapeutic and toxic levels -Lithium toxicity ranges from mild to moderate and severe symptoms depending on blood levels --Severe symptoms include ataxia, ECG changes, clonic movements, seizures, coma, and death -Major long-term risks - hypothyroidism and kidney impairment (not if its when) --Necessity for periodic thyroid and renal function tests

Concepts of the Therapeutic Relationship Patient centered care

-Relationships: 3 types --Intimate: mutual needs met, w/ emotional commitment --Social: needs of both parties met, friendship --Therapeutic: needs of pt met, focus on pt not nurse --initial stage: some disclosure from nurse can occur to build trust but after pt is center -Boundaries: need to maintain, even if pt ask a lot of personal question, nurse needs to establish boundaries --Blurring: blurred lines no longer benefit the pt --Self check on Boundaries: -Roles: transference or counter-transference can happen in the nurse-pt relationship --Transference: pt inappropriately or unintentionally transfers feelings or behaviors onto nurse of a figure of significance in pt's past --Countertransference

Religion and mental illness

-Religion is a common theme in delusions and hallucinations. -Goal of caregiver: distinguish religious experience from psychopathology -Patient with Schizophrenia - concrete interpretation of the abstract Example: The patient hears "let Jesus enter your heart" Abstract "let Jesus enter your heart" Concrete interpretation - literal invasion of body, patient is fearful -Listen to the patient's fear, do not argue or disagree -Let the patient know he/she is safe

Theories for personality disorders

-Research indicates: --Limbic system involvement --Hippocampus smaller than normal --Possible neurological link -Genetics: personality traits inherited -Psychosocial factors: defense mechanisms like repression, suppression, regression, undoing, and splitting are dominant -Cultural factors -we have no idea why or how its happening -need to educate and disprove what they're saying -we need to write down what they say, especially if child is involved, may need to CPS involved

outcomes identification

-identify attainable and culturally expected outcomes -documents expected outcomes as measurable goals -include time and estimate for expected outcomes

Civil Rights of Persons with Mental Illness

-Right to vote -Right to civil service ranking -Right to receive, forfeit, or deny a driver's license -Right to make purchases and enter contractual relationships (unless deemed incompetent) -Right to press charges against another person -Right to humane care and treatment -Right to religious freedom and practice -Right to social interaction -Right to exercise and participate in recreational opportunities **Incarcerated persons - same rights 5th amendment: "no person shall be deprived of life, liberty or property without due process" -should have least restrictive alternative - least drastic means be taken to achieve a specific purpose

Milieu Management for bipolar

-Safety: make sure not effecting others -Staff consistency -Reduce environmental stimuli: tv off, etc -Do not escalate patients -Reinforce appropriate hygiene, dress -Monitor nutrition and sleep -Seclusion and restraints: if danger to self or others

define seclusion and false imprisonment

-Seclusion: confining a patient to an area or room and preventing the patient from leaving -False Imprisonment "Deliberate and unauthorized confinement of a person with fixed limits by the use of verbal or physical means," (Ellis and Hartley, 2012 -Rights Regarding Involuntary Admission and Advance Directives -Rights regarding restraints and seclusion

Consensual Validation

-Seeking consensual validation -"Tell me if my understanding agrees with yours."

Treatment: Antianxiety Drugs (Anxiolytics)

-Selective serotonin reuptake inhibitors (SSRIs): lexipro and prosac more effective (paxil, luvox, zoloft) -first line is SSRI --difficult to have anxiety w/out depression so treating both **MAOI only if treatment resistant -Benzodiazepines: short term treatment(90 days or less); causes dependence (addictive), if taken w/ alcohol = risk of decreased respiration --use until SSRI's reach full effects (2-6wks) --fast acting -Selective norepinephrine reuptake inhibitors -(SNRIs) - Venlafaxine (Effexor) and Cymbalta (good for GAD) -Buspirone (Buspar): used if has greater issues w/ worry or GAD, no depence caused, takes 2-4wks for effectiveness -contra: renal or hepatic issues -SE: headaches, nausea, dizziness -not as dangerous if pregs -Other antidepressants: Zoloft, MAOIs (not generally) -Selected anticonvulsants: Neurotin shows decrease and anxiety, high level effects w/ low side effects -Propranolol: treats physical symptoms like increased HR, shakes, dizziness **an use beta-blocker, antihistamines, anticonvulsants, and antipsychotics

Nursing Process: Assessment

-Self assessment can be done -Standardized depression screening tools -Suicidal ideation: this is when they want to harm self, different than thoughts of death (passive) --access, plan, negative, positive factors -Emotional, cognitive, and physical symptoms -Medical conditions: fam hist, past hist -History/current support system -Triggering events: not always triggering event -Cultural beliefs/spiritual practices: does culture allow for period of depression, is religion a positive protective factor

Nursing Process: Assessment Guidelines

-Self-assessment essential, need to check-in w/ self -Take full medical history, check for past abuse issues, substance abuse -Determine suicidal/homicidal thoughts/self-harming thoughts -Relate personality functions to individual's ethnic/cultural background that contribute -Determine recent important loss: jobs, pets, etc

Concepts of the Therapeutic Relationship Therapeutic Use of Self

-Self-awareness What skills does it take to be self-aware? -Openness -Self-reflection -Assess values and beliefs (stem from our culture - religious, societal forces -guide us in making decisions and taking action -Recognize the patient has different values and beliefs -Respect the Dignity of the Individual

Tactics for Milieu Management: Disruptive Patients?

-Set limits -Use matter of fact tone -Decrease stimuli -Observe for escalating behavior: threatening -Minimize potential weapons -Be judicious when developing consequences -Invoke consequences when violations occur -Provide for patient safety when restraints are necessary -if pt having loose associations, we need to make sure they know we don't understand them, paraphrase comments, etc --sometimes just saying I don't understand you decreases aggression

Nursing Process: Evaluation for Bipolar Disorder

-Short-term and intermediate evaluation focused on goal attainment such as: --Vital signs stable --Hydration and nutrition --Control of behavior or respond to external controls --Sleeping --Understanding of illness and treatment (pt and family) -Long -term evaluation focused on goal attainment (i.e. med compliance, resumption of functioning in community/with family)

Benzodiazepines

-Side effects --Drowsiness, fatigue, sedation --Slow reflexes, confusion, decreased cog funct --ataxia -Abuse potential -Physical dependence -Tolerance -Withdrawal syndrome -Drug-drug interactions -Nursing implications -no alcohol -old people at greater risk for falls when on -Examples: Xanax, Librium, Klonopin, Valium, Ativan, Serax) **Valium, used to be called happy housewife drug **can have paradoxical effects occasionally **causes birth defects, dystonia, cleft lipt, etc

Patient Teaching for schizo

-Side effects -Simple written material -Avoid abrupt withdrawal -sunscreen: more susceptible to sunlight -Take medication as prescribed -Report sore throat, malaise, fever, bleeding: could be developing agranulocytosis -Dress appropriately for hot weather; drink plenty of water --pts have altered temp process(wear coat in summer)

Defense Mechanisms

-Sigmund and Anna Freud identified defense mechanisms as a way of coping with life stressors automatically. The mechanisms protect the self. -automatic coping style to protect pts from anxiety, block conflict, help us deal w/ stress, protect us -Adaptive use of defense mechanisms help individuals meet goals. -Maladaptive use: when several mechanisms are used in excess and/or overuse of immature defense mechanisms. --being maladaptive depends on frequency, intesnity, and duration of use

Signs of Opioid Overdose and Drugs used in Treatment of Opioid Overdose

-Signs of Opioid overdose: slowed or no breathing, pinpoint pupils, slow heart beat or extreme drowsiness - can't wake them up -Death usually stems from respiratory arrest due to the respiratory depressant effect of the drug -Aspirate secretions, insert an airway, mechanical ventilation until Narcan can be given. -Naloxone (Narcan) - opoid antagonist - given IM, SubQ or IV - blocks and reverses the effects of opioid medication - duration short - stay with patient - may need another injection after 2-3 minutes - get help -Evzio - auto injector - one time use only -May be given by healthcare provider, EMT, family member or caregiver

Nursing Assessment

-Signs/symptoms of abuse: no access to money, feel safe, etc -Initial interview -Self-assessment: don't be judgemental -Support systems: help ID these -Suicide and homicide risk -Substance abuse: to numb themselves -Documentation --verbatim statements of who cause injury, body map for injuries, psychical evidence if possible -Refer to CPS or APS as needed -vic usually in a dependent position and can becomes isolated w/ lack of support -suicide is twice as likely if intimate partner violence, even murder suicide -assess for homicide potential: gun in home, alcohol/drug misuse, history of violence on part of perpetrator, extreme jealousy and obsessiveness -drug/alcohol abuse common for vic, usually CNS depressant like benzos

Other Treatment for Depression

-Somatic Treatments and ECT --used for depression, psychotic illnesses, and drug resistant pts -Light therapy - SAD: pts w/ seasonal effective disorder, influences melatonin, 30-45min per day, in morning (but can b 2x/day), medical grade light box -St. John's Wort -Exercise: releases epi - Transcranial magnetic stimulation -Vagus nerve stimulation -deep brain stimulation

What is the Stadard 5 Implementation for practice for psychiatric mental health nursing?

-Stardard 5A: Coordination of care (basic) -Standard 5B: Health teaching and promotion (basic) -Standard 5C: Consultation (advanced) -Standard 5D: Prescriptive Authority and Treatment(basic) -Standard 5E: Pharmacological, Biological, and Integrative Therapies(basic) -Standard 5F: Milieu Therapy(basic) -Standard 5G: Therapeutic Relationship and Counseling(basic) -Standard 5H: Psychotherapy (advanced)

Psychotherapeutic Management After Rape

-Stay with patient: not lots of people in and out -Provide empathy, support, safety - listen and let pt talk - stress pt did right thing to save his/her life -Provide medical care, information: need to know about entire process beginning to end (I'm going to touch your arm, i'm going to take blood) -Move slowly, give rationales for care -Protect rights and maintain confidentiality -Explain to pt long-term signs and symptoms many people experience (provide w/ written info or follow up information) -Shame might interfere with reaching out for support -Referrals ready for pt

Stress Definitions

-Stress - a condition that results from a perceived threat (Richard Lazarus Theory) -Stress - nonspecific response of the body to any demand for change (Selye's definition) -stressor: psychological or physical stimuli or event that provoke a stress response in an organism

Stress related to Anxiety

-Stress - state produced by a change in the environment that is perceived as challenging, threatening or damaging to a person's well being. -Stress can lead to anxiety

Comorbidity for schizophrenia

-Substance abuse disorders -Depressive disorders and anxiety disorders -Suicide -Physical Illness -Polydipsia -have high rate of sub abuse, nicotine highest, w/ alcohol and marijuana --60% of pt use cigs, greater risk for COPD, asthma, and dentition issues --leads to poor nutrition and infections of mouth and heart --die 20yrs earlier on avg than general pop, sub abused further decreases this -10% of pts attempt suicide and 5% complete suicide --5% greater rate than gen pop, nurse needs to complete assessment every time -At greater risk for physical symptoms than gen pop, can't manage own heath and meds, could be impoverished, limited access to HC or needs for HC ---if can access HC can be stigmatized then less likely to come back Polydipsia: excessive fluid intake, occurs in 20% of pts --increase in delirium, hallucinations, maybe compulsive disorder, increased in existing symptoms --polydipsia/hyponatremia is issue if symptoms of psychosis are increasing (20% of pts) --check Na+ levels is stable on meds but experiencing increase in symptoms

Anxiety Caused by Substance or Medical Conditions

-Substance-Induced Anxiety: characterized by anxiety, panic attacks, obsessions and compulsions that develop with the use of a substance. --pain meds, steroids can cause anxiety, meds like Ability can cause akathesia which can look like anxiety -Anxiety due to medical condition: must be able to say they have a med condition to rule out GAD -Direct physiological result of medical condition, such as: --Hyperthyroidism --Pulmonary embolism --Cardiac dysrhythmias --Evidence must be present in history, physical exam, or laboratory findings in order to diagnose -Anxiety Disorder Not Otherwise Specified (NOS): don't meet criteria for GAD or OCD but are clearly experiencing anxiety that is explainable

Inhalant Use Disorder

-Substances - solvents for glue and adhesive, Propellants found in aerosol paint sprays and shaving cream -Thinners such a paint products and correction fluids- Fuels such as gasoline and propane -Can lead to serious problems -Craving and tolerance "sudden sniffing death" from cardiac arrhythmias -Adolescents 12-17 -Inhalant intoxication - toxic substances are used to get a quick brief high- -Small doses - disinhibition and euphoria -High doses - fearfulness, illusions and hallucinations -Inhalants - risky behavior - serious and potentially fatal responses - anorexia, nystagmus, unconsciousness -Serious symptoms: coma, cardiac arrhythmias or bronchospasms -w/drawal:not disorder -treatment: no treatment, can use Hadol if sev. agitation or psychotic effect of med

Dissociative Fugue

-Sudden, unexpected travel away from home and inability to recall one's identity and information about one's past -sub-type of dissociative amnesia -Individual may assume new identity --Lead simple life without calling attention to self --could eventually remember and then have amnesia about time in fugue -always Precipitated by traumatic event --trauma is usually so significant the person doesn't recognize what they're doing when they're doing it

Concepts of Suicide

-Suicide ideation: thought of hurting self --passive suicidal ideation: thoughts of death -Suicide attempt: if had prior attempt, at greater risk for future attempts -Prevalence --10th leading cause of death in US --2nd leading cause of death in adolescents/young adults (10-24) --Rates rise in older age-groups

Facts

-Suicide is the 2nd leading cause of death in ages 10-34. , first is accidents -Suicide must be screened at all levels of care. -Mental health issues must be screened in primary and inpatient care. -Having a mental illness diagnosed in childhood is challenging, difficult, and comes with its own unique guidelines. --kids can start engaging in secondary gain -childhood issues are very specialized, screen for ACEs

Treatment for Bipolar Disorders: Mood Stabilizers

-Used for lifetime maintenance therapy -Lithium carbonate (gold standard, works best) --Therapeutic blood level must be reached for drug to be effective ( usually takes 7-14 days) --Maintenance/therapeutic blood levels between 0.4-1.3mEq/L --Used in combination with antipsychotics or antianxiety meds in initial acute mania

Therapeutic techniques end of interview

-Summarizing -brings together important points and allows the patient to clarify -Encouraging formulation of a plan of action -Exploring and setting priorities --Of all things you said - what is the bothering you the most? -Exploring and setting goals --What is one goals that you would like to set for yourself? -Patient focused -Facilitative -Encourage expression of feelings and thoughts of the patient -Help the patient feel understood. -Encourage problem solving.

THERAPEUTIC MILIEU

-Surroundings and physical environment -Managing behavioral crises -Safety -Suicide risk

Hypertensive Crisis and MAOI's

-Symptoms -Occurs when monoamine oxidase inhibition prevents the breakdown of tyramine, which is used by the body to make norepinephrine -Prevention --special diet (low tyramine) --avoiding medications that contain ephedrine/other psychoactive substances

Conversion Disorder (functional neurological disorder)

-Symptoms that affect voluntary motor or sensory function suggesting a physical condition --Dysfunction not congruent with functioning of the nervous system -Patient attitude toward symptoms --La belle indifference: Lack of concern for symptoms, casually mentions being blind --Marked distress -Common symptoms: emotional sx manifest as physical sx, nausea, pain, seizure disorder(non-epileptic sz), blindness, numbness, loss of senses -Patients are not faking or doing this action on purpose -Comorbidity: depression, personality disorder, ptsd, somatic disorders -Risk factors: hx of physical or sexual abuse -person is not faking it, its unconscious for them, do believe they have a sz disorder, need to do EEG to rule out sz disorder, usually linked to anxiety disorder -stress huge factor in the treatment

Symptoms/Treatment of Serotonin Syndrome (SS)

-Symptoms: abdominal pain, fever, sweating, tachycard, elevated BP, deliruim myaclonas (muscle spasms), mood changes like irritablity, CV shock, death -Treatment --Stop offending agents --Provide respiratory, circulatory support in intensive care environment --Use medications to reverse excess serotonin: cyproheptadine, methysergide, propranolol

Drug Treatment for Alzheimer's Disease

-Tacrine (Cognex) -Donepezil (Aricept) -Galantamaine (Razadyne) -Revastigmine (Exelon) -Memantine (Namenda) **increases acetylcholine levels, cholinesterase inhibitors so decreased breakdown

Outpatient -Talk Therapy or Psychotherapy for Anxiety/depression

-Talk therapy alone -Talk therapy and medication -Suicidal/homicidal - hospitalization Best treatment in outpt for depression and anxiety is psychotherapy and talk therapy -for more pts psychotherapy is sufficient --includes behavioral and cognitive techniques by therapist --if not helping meds like antidepressants added -suicidal or homicidal ideation would be indication for hospitalization -therapist can be nurse practitioner, social worker, or psychologist/psychiatrist

Cycle of Violence

-Tension-building stage: anger occurs -begins w/ minor incidents -person is getting on perpetrators nerves, vic afraid to go home -Acute battering stage: hands are put onto the person -Honeymoon stage: all the apologizing or gifting occurs -Repeat of cycle

Physiological Aspects of Stress

-The Stress Response - Fight flight --walter cannon Long term effects -Short term effects: increased HR, resp rate, plasma FFAs and sugar, increased tri's, muscle tension, decreased fluid loss, inflam

Summary culture

-The responsibility of the nurse is to perform culturally competent care. This is dependent on the nurses self-knowledge and expanded world view: -cultural awareness -cultural knowledge -cultural encounters -cultural skill -cultural desire -The nurse is obligated to do an accurate cultural assessment and adapt the outcomes, planning and implementation of care to meet the patient's cultural needs.

Nursing Interventions and Evaluation

-Therapeutic relationships -Case management -Survivors: from victim, long-term treatment -safety, stabilization, forensic collecting, refer for long-term care -Evaluation: help pt be in signs of recovery, less issues w/ sleep, eating like b/f, calm, could have mild suspicion, return to pre-rape functioning and interest

Transference and Countertransference

-Transference: pt unconsciously and inappropriately displaces onto nurse feelings and behaviors to signif figures in pts past -Counter-transference: nurse unconsciously displaces feelings related to signif figures in nurses's past onto pt

Reversing MCI

-Treat underlying cause (i.e. sleep deprivation) -No pills to slow the the worsening of memory problems -"American Academy of Neurology (AAN) did find encouraging evidence linking exercise with better memory in people with MCI." - Exercise 2x a week increases blood flow to the brain. -Other factors that would help: eating right, staying connected with others, engaging in stimulating activities, participating in new things -No guarantees but the evidence suggests these steps may delay or even prevent progression to dementia

Other Medications to Treat Anxiety

-Tricyclic Antidepressants -Clonidine (Catapres) -Gabapentin (Neurontin) -Pregabalin (Lyrica) -Propranolol (Inderal) ***focus on Neurontin and inderal

Nurse-Patient Relationship

-Trust -Empathy (not sympathy), support, compassion, acceptance -Ask about abuse in calm, matter-of-fact way -Reassure that all experiences and emotions are valid and exploration is the beginning of the recovery process -Reinforce that victim was not responsible for and did not deserve sexual abuse -Emphasize victim not alone -May need to teach stress management, assertiveness, effective parenting (discuss and role model) -Acknowledge that victim handled the situation in best way he or she could at the time -Provide a presence and support during re-experiencing of trauma -Eval -Encourage use of therapeutic anger release strategies (model how they argue to get feelings out) -Confrontation of the perpetrator not necessarily desired or safe (talk about other options if don't want to) -Directly address the need for reporting of abuse (don't pressure, provide w/ resources and encourage to do so) -Do not rush or coerce

Double bind message

-Two or more mutually contradictory messages given by a person in power -opting for either choice will result in displeasure of person in power, aka no win situation -mixed content and process (has both nurturing and hurtful aspects)

What are the Age considerations for an adolescent during an assessment?

-concerned w/ confidentiality -parent must give consent for treatment so have right to info -identifying risk factors is key for this age group **use HEADS SS

Conditional Release and Unconditional Release

-Usually requires outpatient treatment for a specified period to determine the patient's adherence with medication protocols, ability to meet basic needs, and reintegrate into the community Unconditional Release: Is the termination of the patient-institution relationship through court order or admin

Making value judgments & changing the subject

-VALUE JUDGMENTS How come you haven't stopped drinking? Best approach: Tell me about your drinking habits. CHANGING THE SUBJECT Often seen with novices instead of exploring what the patient is saying Patient: I am seeing bugs on the wall. Nurse: Are you having any delusions? Versus - Describe to me what you are seeing.

Nursing Assessment - Suicide

-Verbal cues: vague statements -Behavioral cues: cheeking or hoarding meds -Always ask person suspected of being at risk, -"Are you thinking about killing/hurting yourself?" -Precipitating events/risk and protective factors -Suicide history (family/friends) -Suicide plan (intent, lethality, availability of means,injury) -Determine support systems, including community supports

Working phase of Clinical Interview

-WHAT Data Gathering Precipitating event Explore thoughts and feelings Situation, safety, holistic assessment Focus on here and now situation -HOW Pacing Using therapeutic techniques Silence, statements, questions

Illness Anxiety Disorder

-Widespread phenomenon -Used to be called hypochondriasis (hypochondriac) -Individuals use 41-78% more medical services per year than avg patient (Fink, 2010) -Misinterpreting physical sensations as evidence of serious illness --Negative physical findings does not affect patient's belief that they have serious illness --don't always have physical symptoms but if do they're usually mild -Comorbidity --Depression (ECT been known to help some), substance abuse, personality disorder -Web MD, social media have direct impact on illness anxiety disorder

AIMS scale

-abnormal involuntary movement scale -based on EPS symptoms -complete every 6 months or if any increase in symptoms

Fidelity

-aka Nonmaleficence -Maintaining loyalty and commitment to the patient doing no wrong to the patient -Franciscan values of dignity of the individual, stewardship and peace and justice -Examples: -continuing education -Giving care according to standards of care -Doing extra things for patient - going above and beyond

WHAT IS MENTAL ILLNESS?

-all psychiatric disorder that have a definable dianosis -disorder manifested in signif dysfunction related to developmental, biological, physiological disturbances in mental functioning

Obsessive-Compulsive Disorder

-anxiety disorder, females more effected, physical and sexual abuse can be risk, occurs along w/ other disorders like eating disorders, MDD, bipolar -DSM: recurrent and persistant thoughts, tries to ignore them, repetitive behaviors -can only have obsessions or compulsions and be diagnosed, don't need to have both -Obsession: Thoughts, impulses, or images that persist and recur time and time again -Compulsion: Ritualistic behaviors that individual feels driven to perform (time consuming and interfere with life), need to complete in order to remove the obsession --repetitive behaviors, counting, hand washing, silently repeating words, praying -OCD Interventions: Long term therapy required, allow to complete **different than the OCD personality disorder Obsessions seem senseless to the person who experiences them because they are ego-dystonic. Performing the compulsive act temporarily reduces anxiety. Since it is temporary the compulsion is repeated. o OCD: example would be compulsively going to check if the stove is off or if the door is locked. There are nagging thoughts in the person's head that causes mildly compulsive behavior Pathological obsessions or compulsions cause marked distress to individuals, who feel humiliation and shame regarding their behaviors. The rituals are time consuming and interfere with normal routine. Performances of cognitive tasks are impaired because severe OCD occupies so much of the individual's mental process.

arguments surrounding PAS?

-autonomy -quality of care -non-maleficence -beneficence

What are some things to think about with seating during an interview?

-be at same height, both sitting or standing -don't be face to face (90 or 120 degree side angle more comfy) -don't put pt between self and door, provide exit -avoid desk barrier

coping mechanisms

-behavioral: crying, w/drawal, smoking, using alcohol and drugs, talking about event, becoming extremely agitated, confused, disoriented, incoherent, and even laughing or joking -cognitive: positive and neg, at least I am alive or its my fault this happened -involve pts support system if they're supportive -pay attention to verbal and non-verbal communication through fam -can obtain info through support if pt cant remember certain things

secondary gains

-benefits from symptoms along -if pt derives personal benefit, its more difficult to give up symptoms -PCP's work to achieve healthier avenues to achieve the same benefits -What are you unable to do now that you used to be able to do? -How has this problem affected your life?

What are the Age considerations for a child during an assessment?

-best source for feelings and emotions --caregiver usually describes behaviors, performance and conduct --caregiver can interpret worse and responses but if able do a separate interview --look for age appropriate behaviors --ask them to draw, play games, etc

resilience

-capacity for people to secure resources they need to support their well-being

What was the first mental health med?

-chlorpromazine (Thorazine), in 1052 -in 1979 consumer movement occurred w/ NAMI and idea of recovery -1999 first surgeon generals report on mental health came out, said its part of health and has treatments -1990-2003: Human genome project -1978: Rosalyn Carter made President's New Freedom Commission on Mental Health -2013: Obama BRAIN Initiative -2013: Research domain criteria (RDoC) initiative

Developmental Aspects of depression in Older adults (>65)

-common but not normal result as aging -but health goes down and chronic disease risk goes up as well as if losing independence risk goes up

What are 4 areas nurses struggle w/, w/ cultural considerations?

-communication style -use of eye contact -perception of touch -cultural filters (how we see the world)

Diagnosis

-identify problem and etiology -construct nursing diagnoses and problem list -prioritize nursing diagnoses

Involuntary Admissions

-court ordered admit w/out consent --pt needs to be threat to self, others, gravely disabled or in need of treatment that can not have b/c mental status -72 hour hold -Petition for court hearing -Court hearing -results: No commitment Temporary Commitment Regular Commitment -pt can argue writ of habeas corpus (unlawful detention) or least restrictive alternative doctrine

INPATIENT CARE admission criteria?

-danger to self -danger to others -gravely disabled --so far from baseline, can complete basic needs

Nursing Interventions Classification (NIC)

-defines nursing inteventat as any treatment based upon clinical judement and knowledge that nurse persform to enchnace pt outcomes -7 domains:basic and complex physiological, behavioral, safety, family, health system, and community

Delusional Disorder

-delusions, don't typically impair functioning, but pt fixated despite evidence of meds -last 1 month or longer -have general theme of grandiose, persecutory, somatic, and referential delusion -not sev enough to impair occupations

stages of kuber-ross death and dying theory

-denial and isolation -anger -bargaining -depression -acceptance -be present, provide supportive care, manage symptoms -fam can have anticipatory grieve --encourage fam to off water as long as pt can take it orally, helps remind pt is dying of illness not lack of sustenance

rights regarding psychiatric advanced directives

-designation of preferred PA and therapist -appt of someone to make MH decisions -pref w/ med to take or not take -consent or lack of consent for ECT and admission to a psychiatric facility -preferred facilities and unacceptable facilities -individuals who should not visit

Evaluation during nursing assessment

-document results of evaluation -if outcomes have not been achieved at desired level: -additional data gathering -reassessment -revision of plan

Beneficence

-duty to act to benefit or promote good of others -Nursing care of pt using nursing process, following standards of care -Specific interventions in mental health --Providing a safe milieu --Respectful listening of the patient --Doing best for pt, especially safety

Justice

-duty to distribute equally resources or care regardless of personal attributes of the person ----Franciscan value: Peace and justice and stewardship ---Examples of just care to all patients

Traditional/Conventional Antipsychotics (first gen)

-effect positive symptoms but not neg (affective) -severe side effect profile (EPS) -Action: dopamine antagonist at D2 receptor sites in both limbic and motor areas of brain Disadvantage: side effect profile is severe -Major Side Effects: Extrapyramidal symptoms --Tardive dyskinesia --Dystonia --Akathisia: general internal restlessness --Akinseia --Drug-induced parkinsonism -Neuroleptic Malignant Syndrome -Agranulocytosis: issue w/ 1st and 2nd gen --can cause neutropenia, need baseline counts -anticolinergic toxicity: mental status changes, worsening of psychosis --older adults on lots of anticolinergics get (need to distinguish is it toxicity or psychosis) -Prongloned QTC= abnormal HR = torsades =MI --haladol, thorazine

counseling

-emphasize pts have right to live w/out fear of harm -develop safety plan -help id sings of escalation -come up with code word to leave for kids -shelters or safe houses available -promote community support and make referrals (jobs, parenting resources, financial assistance)

What are some attending behaviors during the interview?

-eye: depends on culture, general rule: maintain when pt speaking but not when nurse speaks -body language: kinesics and proxemic --kinesics: physical characteristics like body movements and posture --proxemics: study of personal space -vocal quality: can improve rapport, demonstrate empathy and interest, and add emphasis

What are the 3 characteristics of a nurse that Rogers and Truax identified to help promote growth and change in pts?

-genuineness: openness and honestly -empathy: we understand vs sympathy is i feel bad for you -positive regard: seeing others as worthy of care --attending --suspending judgement --helping pts develop resources

Active Listening

-giving pt undivided attention and eye contact -active listening means nurse fully concentrates understands, responds and remembers what the patient is saying verbally and non-verbally -undivided attention lets pt know they're not alone Examples of not actively listening would be (1) the nurse doing other things while the patient is talking versus giving undivided attention and eye contact (2) Cultural aspects -focusing on our hand held devices and not actively listening to the person in front of us

Patient Centered Care

-gold standard -dignity and respect -info sharing -pt and family participation -collab in policy and program development -nurse pt relationship needs to establish nurse is safe, confidential, reliable, and consistent that relationship will occur w/in appropriate boundaries

physical exam

-head to toe, look for injury -detailed genital exam, look for sings of injury -evidence collection and preservation -doc finding both written and photo -treatment, discharge planning, and follow-up care **need informed consent -many cases of sex assault have not physical signs of injury -reduce revictimization when doing physical exam by explaining procedure and providing support

Interventions for mild-mod anxiety

-help patient identify anxiety -anticipate anxiety-provoking situations -use nonverbal language to demonstrate interest -encourage pt to talk about his or her feelings or concerns -avoid closing off avenues of communication that are important for pt -ask questions to clarify what is being said -help pt id thoughts or feelings b/f onset of anxiety -encourage problem solving w/ pt -assist developing alternative solutions to a problem through role play or modeling -explore behaviors that have worked to relieve anxiety in past provide outlets for working off excess energy (walking, etc)

health promo

-help recognize behaviors and situations that might trigger violence -explain normal developmental and physiological changes to enable fam to gain more positive view of vic, increases compassion -maternity nurses can id at risk parents: new parents who are rejecting, hostile, or indifferent, teenage parents, parents w/ cognitive deficits, parents who grew up watched mom get abused

Neurotransmitters

-monoamines: norepi, dopamine, serotonin -dopamine: decreased in parkinsons and depression --increased in schizo and mania norepi: decreased in depression --increased in mania, anxiety, schizo --arousal, stims SNS serotonin: decreased in depression --role w/ sleep regularly, hunger, mood, pain perceptions, hormonal activity histamines: decreased = sedation, WG GABA: decreased in anxiety, schizo, mania, huntingtons --aggression, excitation, anxiety, pain perception, anticonvulsant and muscle relaxing properties, impairs cog and psychomotor function glutatmate: decreased in psychosis --increased in Alzheimer (increased =decreased memory) **drugs used to treat emotional disorders cause movement disorder and visa versa **dopamine and glutamate effect schizo

stigma of mental health

-more severe and prev than in US -mental illness seen as failure of family -pressure on fam and individual are increased and reflects badly on character -shame leads to not getting care or in an advanced stage misdiagnosis occurs: -AA diagnosed as shizo when actually bipolar b/c cultural differs -somatization occurs b/c mind-body seen as one, leads to wrong diagnosis -use Cultural Formulation Interview

What are the statistics about mental health?

-no health without mental health. -inequality in mental health care funding. -1:6 Americans take medications for mental illness -Mental Health Problems Affect Everyone -1 in 5 American adults experienced a mental health issue -One in 10 young people experienced a period of major depression -One in 25 Americans lived with a serious mental illness, such as schizophrenia, bipolar disorder, or major depression -Suicide is the 10th leading cause of death in the United States. It accounts for the loss of more than 41,000 American lives each year, more than double the number of lives lost to homicide.

Exploring

-nurse examines thoughts and feelings more fully --Pt "I do not get along with my wife." -Nurse" Tell me more about your relationship with your wife." OR -"Describe your relationship with your wife."

Nurse's role

-nurse to provide holistic care and address all aspects of the patient's needs. -Patient's who have physical or mental illness have spiritual needs, particularly in a health crisis. -Nurse's sometimes fear discussing spiritual needs because of lack of preparation and avoid assessing. -It is most important that the nurse be caring and authentic and listen to the patient express his or her fears and concerns. If the nurse feels uncomfortable, she or he can always call another nurse to assist the patient or call the chaplain.

ANA Code of Ethics

-nurse's primary commitment is to the recipients of nursing and health care services - patient or client - whether individuals, families, groups, communities or populations **need to post pt rights where treatment given

Nursing Diagnosis and Outcomes Identification for bipolar

-nursing diagnosis: depends on stage -Outcome identification - acute phase: hydrate, high cal foods, at risk for CV issues in hyper-manic phase - continuation of treatment phase - maintenance phase: make sure staying on meds

what are the key elements to health and well-being?

-nurtured -active -respected -responsible -included -safe -healthy achieving

Brain Structure Abnormalities

-oxidative stress, infection, autoimmune disease can cause -reduced vol in right anterior insula (contribs to neg symptoms) -reduced vol and changes in hippocampus -accelerated age-decline in cortical thickness -gray matter deficits in dorsolateral perfrontal cortex, thalamus, etc -reduce connectivity amoung brain regions -white matter abnorms -PET shows increased glucose and slower blood flow

Implementation with Dementia -Alzheimer's Disease

-patient-centered approach -refer to community support -patient and fam teaching for: --dressing and bathing --nutrition --bowel and bladder function --sleep

what are the types of delusions

-persecutory: believes being singled out for harm -referential: believes events that have nothing to do with them is somehow related -grandiose: bel. very important -erotomanic: bel. another person desires you -nihilistic: thinks major catastrophe will occur -somatic: bel. body is changing in unusual ways -control: bel. something else is controlling them

Disruptive Mood Dysregulation Disorder

-persistent pattern of irritability and anger -created b/c children were being diagnosed w/ bipolar which is an adult illness -onset b/f age 10 -tantrums, outburts at home or school -not a lot of info for treatment, new illness -meds for ADHD can help b/c symptoms are similar ---need to watch SE: increased BP, anorexia, not sleeping -antipsychotics: risperdol and abilify good for mood --SE: Met syndrome, akathesia, etc

when planning interventions, what are some other things to take into consideration?

-poor hygiene -resistance to treatment, non-adherence -cheeking or palming medication -anosogosia -avoid interactions with peers -depression, hopelessness, and despair -poor self-esteem -fall risk -choking risk -restlessness, agitation -risk for other-directed violence -risk for self-directed violence

Psychological and Environmental Factors

-prenatal stressors (if mom had infection or mental illness, if father older than 35, if child born in late winter or early spring) --stress: any induction of the cortisol levels plays role in development --any abnormal childhood experiences like sexual abuse, exposure to poverty, trauma w/ self parents or grandparents --chemical toxins, high crime areas

Drugs used in Treatment of Opioid withdrawal long term maintenance

-promote breathing: open airway, remove secrections -give Narcan (opioid antagonsit)IM, subQ, or IV, fast half life so monitor -CBT, family therapy, social skills help Buprenorphine (Subutex) Opiod partial agonist -Advantage - weaker opioid effects and less likely to result in an overdose -Longer acting and produces a milder withdrawal syndrome -Alleviates cravings, reduces use of illicit opioids, milder neonatal withdrawal and increase retention in therapeutic programs Three formulations of Buphenorphine -Subutex (Buphenorphine), sublingual - given first -Suboxone (Buphenorphine + Naloxone) - given long term, sublingual -Probuphine (buphenorphine), surgically implanted rods -Naltrexone - maintenance after detox - opioid antagonist and block euphoric effects; Vivitrol injection given once a month; decreases cravingRevia --Naltrexone (Vivitrol) - opioid antagonist for prevention of relapse to opioid dependence --Could die if get vititrol and and opioid -SE: weakness, insomnia, irritability, fainting, decreased sex drive

Caffeine

-psychoactive sub -not a disorder but can result in intox and w/drawal --Intoxication: -restlessness, excitement, agitation, rambling speech -physical sympt: Flushed face, diuresis, G.I. symptoms, muscle twitching, tachycardia or cardiac arrhythmia -extremely high doses - seizures, respiratory distress, death -excessive use associated w/ bipolar, eating disorders, and sleep -3-10hrs --Withdrawal - headache, drowsiness, irritability and poor concentration, some have flu-like symptoms -occurs 12-24hrs last 1 week, no issues w/ w/drawal

mental status examination

-purpose is to evaluate individuals current cognitive processes -collects and organized objective data Looks at: -appearance -behavior -speech -mood -disorders of thought -perceptual disturbances -cognition -ideas of harming self or others

diathesis-stress model

-represents biological predisposition and stress represents environmental stress or trauma -most accepted explanation of mental disorders

What are 4 principles for planning an intervention?

-safe -compatible and appropriate -realistic and individualized -evidenced-based

Sexual offenders

-spousal rape and acquaintance rape (date rape) most common -psychological outcomes vary based on level of intimacy -sexual distress more common if assaulted by intimates -fear and anxiety more common if assaulted by strangers -increase in date rape drugs

Nursing Outcomes Classification (NOC)

-standardized outcomes and definitions of these outcomes -5 point Likert scales used w/ all outcomes and indicators (5 is best, 1 worst) -490 outcomes w/ seven domains: functional health, physiological health, psychosocial health, health knowledge and behavior, perceived health, family health, and community health -psychosocial domain has 4 classes: psychological well-being, psychosocial adaptation, self-control, and social interaction

WHAT IS MENTAL HEALTH?

-state of well-being in which individual able to realize his/her own potential, cope w/ normal stresses of life, work productively, and make a contribution to the community -provides capacity to think rationally, communicate, emotionally grow, and have resilience and self-esteem

Brief Psychotic Disorder

-sudden onset of psychosis, symptoms longer than a day but less than a month --pts return to normal functioning typically --due to stressful event --usually females

Rape Trauma Syndrome

-sustained and maladaptive response to forced, violent sexual penetration against vic's will and consent -psychical and psych effects of rape -Sleep disturbances, nightmares --triggering events occur -Anorexia, amotivation -Fears, anxiety, phobias, suspicion -Relationship disruptions -Self-blame, guilt, shame -Lowered self-esteem -Somatic symptoms: if they have to leave house or do things they don't want to --N/V, sweating, chest-pain, headache common

psychotherapy

-talk therapy -evidence suggests that pscyhotherapy w/in therapeutic partnership actually changes brain chemistry -good for psychiatric problems less so w/ psychotic disorders (used combo of med and pscyhotherapy) **counseling: supporvite face-to-face process for problem-solving, personal conflicts, and support

Emergency commitment

-temp admit or ER hospitalization -for those who can't make own decisions or so ill they need emergency admit -anyone can initiate court proceedings -used for observation, diagnosis, treatment -24-96hrs -court hearing held for vol or invol committment

Schizophrenia has Distubances in:

-thought -psychosis needs to be present: hallucinations, delusions, disorganized thinking -self-care: can't manage hygiene -executive thinking -changes in social functioning -disturbance for 6months w/ 1month of symptoms of psychosis -diagnosis requires at least one psychotic trait

Neuroleptic Malignant Syndrome

-triad of symptoms that requires immediate medical intervention -extreme temp -muscle rigidity -confusion

malpractice

-type of negligence -has to have these 5 elements: -duty: assumed care -breach of duty: don't meet standards of care -cause in fact: nurse caused harm -proximate cause -damages: actual damage occured

What is considered to be a message in communication?

-verbal: content of message -non-verbal (visual, tactile, smell, silence: process of message -both verbal and nonverbal (may contradict or substantiate) **important that content and process are congruent

What are the requirements for admission?

-vol or invol doesn't determine pts ability to make informed decisions -need DSM diagnosis -pt should be in crisis or less restrictive alternatives are inadequate or unavailable -reasonable expectation treatment will help

INPATIENT CARE Types of admissions?

1.)Immediate detention (ID) --only police can do this, not criminal, have to immediately transfer you to facility w/ psychiatric care, doc has 24hr period to assess for further care, 24hrs hold then could be transferred home or to outpt facility, if determined need more care then emergency detention(physician driven) 2.) Emergency detention: --forms filled out by medical doc, doc sends papers to probate court who agrees or disagrees, gives doc 72hrs to determine if need more care or transferred to least restrictive care, if need more treatment then temp. commitment (physician driven) 3.)Temporary commitment: 90 day commitment to services, doesn't mean 90 days of inpt, just treatment, doc has 90 days if pt needs further level of care (regular commitment) or not (court driven) 4.)Regular commitment: yr long commitment (takes meds as prescribed, no drugs or alcohol, etc), if they don't complete commitment police pick them up and have them transferred to facility of need (court and physician driven)

Co-occurring disorders

Any combination of two or more substance use disorders and mental disorders identified in the DSM V. Mental illness is common with substance use disorder. Individuals suffering from major depression, bipolar disorder, and/or anxiety disorder are twice as likely to have a substance use disorder than the general population. This is common in persons with antisocial personality. One-half of persons with schizophrenia have a substance use disorder. A study conducted in 2014 reported that 20 million people have a substance use disorder. Of these, 7.8 million have a co-occurring disorder.

Communication: Verbal and non-verbal

Application with persons with mental illness Nonverbal - important source of data about the patient's illness, can include tone of voice Example: --Patient with depression --Patient with psychosis --Patient with mania _all these illnesses would show verbal and non-verbal s/sx, we need pay attention -non-verbal is congruent (matches) or non-congruent (smiles when angry)

Spirituality and suffering

Attention to patients' spiritual concerns...may help patients identify the resources in their own religious traditions that can help them cope with the suffering caused by mental illness

Attention-Deficit and Disruptive Behavior Disorders

Attention-deficit/hyperactivity disorder -Most common reason children are seen in mental health treatment -must be diagnosed b/f age 12 Oppositional Defiant Disorder -First seen in preschool aged children, defiant w/ all adult caregivers and locations --very difficult for the parent, nothing parent can do to please child Conduct Disorder -Left untreated will likely develop to Antisocial Personality Disorder --start breaking things, hurting people, etc

Structure and Function of the Brain

Brainstem: Controls survival functions, has limbic system in it Hypothalamus: Hunger, thirst, sex, sleep/wake cycle Cerebellum: Regulates voluntary movements Cerebrum: mental activities and a conscious sense of being.

Adverse Childhood Experiences (ACE): CDC 2016 study determined as the number of ACES increase the following medical and mental health conditions increase

CDC 2016 study determined as the number of ACES increase the following medical and mental health conditions increase: -Alcohol Use Disorder -Cardiac Problems -Fetal Death -Financial Stress -Intimate Partner Violence -Sexual activity at a young age -Liver Disease -MDD -Mulitple Sexual Partners -Poor academic performance -Poor work performance -Unintended pregnancies -STIs -Smoking -Suicide attempts -resilience, intelligence, and supportive environment can aid in avoiding mental disorders

DSM-v Clusters of Personality Disorders

Cluster A: odd or eccentric behaviors -Paranoid PD -Schizoid PD -Schizotypal PD Cluster B: dramatic, emotional, or erratic behaviors -Borderline PD -Narcissistic PD -Histrionic PD -Antisocial PD Cluster C: anxious or fearful behaviors -Avoidant PD -Dependent PD -Obsessive-Compulsive PD Personality Disorder Not Otherwise Specified NOS): may have aspects from multiple clusters, further testing is usually done

Treatment for Anxiety Disorders

Cognitive - Behavioral Therapy (CBT): really focus on talk therapy b/c meds have limited effect on anxiety disorders -Therapist teaches patient to: -Examine assumptions -Redefine fears -Restructure thinking -Make changes -Breath restraining -Benefits of CBT: life long, can learn to cope effectively w/out meds -Cog therapy: cognitive restructuring -Behavioral therapy: modeling, systemic desensitization, flooding, response prevention, thought stopping

Nursing Care of Older Adults: Assessment

Comprehensive Holistic Assessment -Functional (Activities of Daily Living) -Physical (body systems assessment) -Cognitive (mental status exam) -Psychological --quality of life --Depression -Geriatric depression scale (1983) --Suicide --Anxiety -Social -Spiritual

Brain Imaging Techniques

Computed tomography ( CT scans) Magnetic Resonance Imaging (MRI scans) Positron Emission Tomography (PET scans) Single-photon emission computed tomography ( SPECT scans) **PET shows decrease glucose in frontal lobe if schizo and lower brain activity (reasoning skills) ---detects mood disorders and ADHD **CT/MRI show schozo

Mild Cognitive Impairment (MCI) Types and Symptoms

Excludes people with dementia Symptoms - two types (not severe but may be upsetting or disruptive Amnesic MCI - memory issues - forgetting conversations and misplacing items Non-amnesic MCI - "Involves changes in other brain activities regardless of whether you have memory loss." - problems with language, lose train of thought in a conversation, hard time accomplishing tasks like paying bills or problems with spatial sense - can't find your way around a familiar place.

Getting substance user into treatment

Denial can be strong -Sometimes needs to feel the consequences of using/drinking to seek treatment -Job loss -Loss of spouse -DUI's - legal issues - may be 3rd DUI Assessment of drinking? How much do you drink? -The more honest you are the better we can treat your withdrawal and the easier for you it will be. -Typical Alcohol use - one-fifth a day -750 cc -Polysubstance use - ask what other drugs

Getting help! - Al-Anon

Denial is strong and therefore, difficult to get person in treatment If substance user not seeking help, family member(s)/significant other needs to get help & support - Al-Anon - 12 step program - multiple groups nationwide Substance user affects everyone around - Family affected - gets caught up in an unhealthy cycle of communication (victim/persecutor/rescuer) Helps family member focus on oneself instead of the substance user Multiple books available to help. Takes a daily effort - changing way of thinking Al-Anon good for anyone dealing with a user of any kind of drugs

Intervention strategies with the older adult

Environmental Psychosocial Pharmacological Self-care Safety Care settings -Older adults have unique needs. -A thorough holistic assessment is needed because of the complexity of physical and mental issues.

Etiology & Risk Factors of Alzheimer's Disease

Etiology Genetic Theories Anatomical Pathology of Alzheimer's Risk Factors: first degree relative, genetic mutations=APOE, e4, e3 allele, hippocampus shrinks and so do cerebral cortex, accumulation of beta-amyloid and accum of tau proteins forming tangles --Age: 65 and older --Gender: both male and female --Cardiovascular Disease --CVD could increase --Social engagement and Diet --Head Injury and Traumatic Brain Injury

Mental Health and Culture

Examples of Cultural Views of Mental Health/Illness Western tradition values autonomy, individuality, independence and self-reliance, dualism -disease has a specific, measurable, and observable cause, providers eliminate cause -time is linear Eastern tradition values family as the basis of one's identity - values family interdependence and group decision making, holism (body/mind/spirit) -don't separate physical and mental illness -time is circular Culture shapes the expression and recognition of psychiatric problems. Need to look at: -nonverbal communication -etiquette -beliefs and values What the person determines as mentally healthy or mentally ill is dependent on the "lens of the person's culture.", what's normal -watch out for ethnocentrism: universal tendency of humans to think their way of thinking and behaving is correct and natural way

Guidelines and treatment for Antisocial Personality Disorder

Guidelines -Monitor manipulation -Monitor for violence -maintain safety -Coping skills should focus on healthy behaviors, effects of decisions on own life, taking responsibility, abusive self-restraint, aggressive self- restraint, social interaction -need to provide info about consequences for behaviors -provide consistency, boundaries, and limits Treatment: Medications -Mood stabilizers -Antidepressants -Benzodiazepines Long term treatment -Therapy -Medication mgt.: no specific --lithium, depakote for agression --SSRIs like Prozac or Zoloft --benzos if anxious -Understanding how actions cause distress in clients life. -nurse diag: defensive coping, risk for violence, impaired social interaction -NOC: abusive behavior restraint, aggression restraint, oping, social interactions, health promo behav -provide realistic choices, difficult to build relationship b/c hostile and distrusting

Guidelines and treatment for Schizotypal Personality Disorder

Guidelines -Respect isolation -Be aware of peculiar religious practices, thoughts or beliefs, so don't be judgemental, respect their isolation -Be aware of suspiciousness and adhere to schedule. -do assessment for suicide -may need written instructions Treatment -psychotherapy (could be involved in strange religions or cults) -Low dose antipsychotics -Antidepressants -Antianxiety **med only treats portion, long-term therapy necessary

Guidelines and treatment for Obsessive-Compulsive Personality Disorder

Guidelines: -Avoid power struggles -Help cope with unexpected changes -Provide structure; allow for habits, no compulsions but do have habits -Help identify ineffective coping -Assertiveness but not aggressive Treatment: -Long and complicated treatment -Group and Individual therapy -Meds --Anafranil (TCA) --SSRI's

Guidelines and treatment for Narcissistic Personality Disorder

Guidelines: -Avoid power struggles -Remain neutral -Role model empathy, can be taught even though its not natural to them -Do not engage in power struggles -Do not allow negative remarks to cause emotional distress -underlying reason for this is b/c they're shameful and have fear of abandonment -not likely to seek treatment on their own, mostly referred by partners Treatment: -CBT: looks at faulty thinking -Group therapy: can sometimes see their personality traits in others -Lithium and antidepressants

Guidelines and treatment for Avoidant Personality Disorders

Guidelines: -Friendly, accepting, and reassuring approach -Ease into social situations -Attitude of acceptance towards fears -Encourage social skills but monitor anxiety or embarrassing situations that could decrease self-worth -Provide assertiveness training Treatment: -Individual and group therapy -Anti-anxiety agents -Antidepressants -beta-blockers (atenolol) help SNS activity

Guidelines and treatment for Borderline Personality Disorder (BPD)

Guidelines: -Monitor for aggression to others, b/c emotional dysregulation -Self harming, hurting others -Assess past hx of trauma/sexual trauma -Be consistent with staff, avoid splitting -Monitor manipulation, point it out -Minnesota multiphasic personality inventory -clear, consistent, boundaries and limits Treatment: -No approved medications -Meds are used to treat sx --Antidepressants --Antipsychotics: low doses (seroquil), Naltroxone used to lower emotional liability (normally used w/ alcohol --Mood stabilizers --Opioid Receptor antagonist --DBT (dialectical behavior treatment): best treatment --marsah lenahan developed --helps pts identify where they are on a spectrum of emotion, 1-low scale emotional need vs 10-high scale emotional need --identifies quality of life behaviors -CBT and schema-focused therapy -manifests when younger, admitted to hosp for rage, danger to self, paranoia depression, etc -need to learn one skill at a time, don't expect to see improvement other than not hurting self w/ immediate treatment -need therapeutic relationship b/c pt usually has failed relationships, watch for manipulative behaviors like flattery, seductiveness, instilling guiding -need clear boundaries (suicidal, self-mutilating, aggressive, manipulative, psychotic), straightforward language -No meds, could use SSRIs, anticonvulsants, lithium

Guidelines and treatment for Histrionic Personality Disorder

Guidelines: -Professional communication, really good boundaries -Monitor for exaggerated sx, point them out to orient back to reality -Role Model assertiveness: teach and role model it so they know difference between that and aggression -Assess suicidal ideations --usually have suicide gestures: attention seeking attempt, can result in completed suicide -Note that seductive behavior is a response to distress Treatment: -Group therapy-watch for disruption in group -Individual therapy (psychotherapy) -Meds, no specific meds approved --Antidepressants (for somatic sympts) --Antianxiety --Antipsychotics: if Illusions, derealization

Guidelines and treatment for Paranoid Personality Disorder

Guidlines: -Adhere to schedules (b/c mistrust) -Avoid being "too nice" -Avoid joking, can't distinguish sarcasm (use neutral affect) -MOF(matter of fact) approach with limit setting -Simple language, may even want to write things down -Be kind and consistent Treatment -Often reject treatment, don't recognize their paranoid immediately -Psychotherapy: to develop a trusting relationship, primary treatment -Group therapy: is often initially threatening but may improve social skills, causes more paranoia -Medications: Antianxiety (Valium) may reduce agitation and anti-psychotics (haloperidol) to treat delusions --may have underlying anxiety -need to distinguish if paranoid delusions or paranoid personality disorder --paranoid personality disorder: distrusting and suspicious, but don't believe FBI is out to get them or the devil is coming for them, that's a delusion or paranoia

Mood Stabilizers

Lithium: bipolar (manic-depressive), decreases glutamate --SE: tremor, bradycard, convulsions, polyuria, edema, hypothyroid, hyponat (watch for toxicity and monitor blood levels) Anticonvulsant Drugs --Valproate (Depakote, Depakene) --Carbamazepine (Tegretol) --Lamotrigine (Lamictal) --Gabapentin (Neurontin) --Oxcarbazepine (Trileptal) -treat bipolar -Depakote: treats rapdi cycling -SE: tremor, WG, sedation, thrombocytopneia, pancreatitis, liver failure -monitor blood levels, CBC, liver enzymes -tegretol:watch for anticolingeric effects and steven johnson syndrome -Lamictal: maintenance for bipolar, watch for steven johnson's syndrome

Importance of self-assessment

Most people affected by alcohol or substance use in some way Have preconceived thoughts and attitudes Demands self-introspection and self-awareness so can approach the patient nonjudgmentally Assisting nurse peers affected by substance abuse - report to manager - nurse needs peer assistance programs

Somatoform Disorders

Prevalence -Rate unknown; estimated that 38% of primary care patients have symptoms with no medical basis 55% of all frequent users of medical care have psychiatric problems Comorbidity -Depressive disorders, anxiety disorders, substance use, and personality disorders common

Prevalence and Comorbidity for bipolar

Prevalence -Lifetime prevalence in US - 3.9% -First episode common between age 18-30 Comorbidity -75% of patients diagnosed with anxiety disorders --avoid benzos when treating (use Busbar, propranolol) b/c benzos have greater risk for sub abuse -Substance abuse -Medical condition: have any that look like mania (need to rule out), can have higher incidence of other issues like sub abuse -bipolar II common w/ binge eating disorders

Delirium Tremens - Goal is to prevent!!

Prevent DT's by assessing for early withdrawal symptom and medicating with a benzodiazepine (Ativan) DT's - Delirium Tremens - may happen any time in the first 72 hours Dangerous - can result in death in 20% of untreated patients -result in pneumonia, renal disease, hepatic insufficiency, or HF if not treated Signs and Symptoms of DT's - Diaphoresis, tachycardia, fever, anxiety, insomnia, hypertension, delusions and visual and tactile hallucinations **pancreatitis can increase risk May be seen on a medical floor - at risk after cessation of alcohol for 3 days. Goal - prevent DT's as can't be reversed - treat the symptoms Valium IV - safety of patient - dim room - reduce stimuli in room - IV's for dehydration --seclusion may be necessary

Factors with Alcohol Substance Use

Progression -Social drinking---escape drinking--- alcohol substance use disorder -Can so slow or fast in different stages. Psychological factors - use of defense mechanisms - very common -Denial - "I don't have a drinking problem - I just have a couple of drinks a day. -Rationalization - " I need to drink because of all the stressors on the job. That's how I cope and stay employed." -Projection -"I don't have the problem you do - you are so sensitive about my drinking."

Nursing Process: Assessment, DID

Rule out medical illness, substance abuse, and other psychiatric disorders -ask about temporal lobe epilepsy, concussion Note signs of dissociative disorder -Changes in behavior, voice, dress (can be different sexes -Referring to self by another name or in third person -Partial memory or memory gaps -Disorientation to time, place, person -Presence of blackouts, time gone they can't explain -Gather info about events in patient's life -Similar episodes in history -Note mood changes -Determine effect of patient problems on family, daily functioning, and employment -Determine suicide risk -Safety is a big deal, we need to identify and address if at suicide risk or danger to other, may need to use restraints -eval if anxiety or signs of dissociation, Id support systems, refer to therapist -pts seek treatment for depression and anxiety feeling unreal or forgetting things --have trouble keeping jobs and relationships

Nursing Diagnoses of the Older Adult

Self-Care Deficit -Bathing/Hygiene Imbalance Nutrition-Less than Body Requirements Risk for Infection Ineffective Breathing Patterns

• Hoarding Disorder

o Accumulation of belongings that may have little or no value us an obsession that prevents some people from leading normal lives. o Guest can or will no longer visit. Every space in the house is filled. o More common in women who seek treatment. o Indecisiveness associated with it and depression

• Agoraphobia

o An intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available. o The feared places are avoided in effort to control anxiety. o These people tend to also avoid being home alone, in a car, bus, plane, bridge or riding on an elevator. o Adverse child events, fam that's cool and overprotective -being with another person can help Panic disorder with agoraphobia -Panic attacks combined with agoraphobia -Feared places avoided, restricting one's life --difficult time leaving home --we need to lower anxiety, until more calm --stay w /them during sev. or panic attack, remind them they are safe/in safe place

Epidemiology

o Anxiety disorders are the most common form of psychiatric disorders in the US. o Nearly 3 quarters of those with an anxiety disorder will have their first episode by age 21.5. o Women are more affected than men o OCD has an average age of onset of 19, a one-year prevalence rate of 1% and about 50% of cases are considered to be severe. o Body dysmorphic disorder is about 2.4% of the population and more frequent in women and rate may be high as 15% for those undergoing plastic surgery. o Hoarding disorders become more evident as people age (2 to 4% of populations) o Hair pulling and skin picking disorder are difficult to identify since people hide them.

Clinical signs of bulemia

o Bradycardia, orthostatic changes, arrhythmias, cardiac arrest, murmur, incr. bicarb, hypokalemia, dehydration, decrease chewing, Russell's sign (callus on knuckles from self-induced vomit) o Normal to slightly low weight, dental caries/tooth erosion (vomiting), parotid swelling, scars on hand (russell's sign), peripheral edema, weak muscles, hypokalemia/natremia, cardiac failure

Social Anxiety Disorder

o Called social phobia. Characterized by fear or anxiety when exposed to a social or a performance situation that could be evaluated negatively by others. o Triggers: fear of saying something foolish in public, not being able to answer questions in classrooms, looking awkward while eating or drinking in public and performing badly on stage. o Small children with social phobia may be mute, nervous and hide behind their parents. o Older children or adolescents may be paralyzed by fear of speaking in class or interacting with other children. The worry over saying the wrong thing or being criticized immobilizes them. o Fear of public speaking is the most common manifestations. -shyness is genetic, adverse childhood experience, chronic isolation = risk for depression

Body Dysmorphic Disorder

o These people have a preoccupation with an imagined defective body part resulting in obsessional thinking and compulsive behavior, such as mirror checking and camouflaging. o Some people may be well aware of their thoughts are distorted or they may be completely sure about existence of the defect. o False assumptions about the importance of appearance, fear of rejection by others, perfectionism and conviction of being disfigured lead to overwhelming emotions of disgust, shame and depression. o Patients are frequently concerned with their skin, hair, nose, stomach, teeth, weight and breast/chest. o Complusions of mirror checking

Separation Anxiety Disorder

o This is normal part of an infant development. It begins around 8 months of age and peaks around 18 months and declines after that. o Developmentally inappropriate levels of concern over being away from a significant other. o There is also a fear that something horrible will happen to them and it will result in a permanent separation. o The person's anxiety is so intense that it distracts them from normal activities and can cause sleep disturbances. o Can cause GI disturbances and headaches. o Adults with this disorder typically have issues in romantic relationships and often unmarried. They are needy and clingy. o These people are shy, uncertain, worrisome, avoid harm and lack of self-direction. o Can be from trauma, loss moving, genetic Have other comorbs -doesn't respond to CBT

Schizophreniform Disorder

o looks like schizophrenia w/ symptoms being shorter, less than 6 months --impaired social function is not as apparent or severe as in schizophrenia --usually use if symptoms are less than 6 months, if goes longer than get diagnosis of schizophrenia --could return to normal functioning

Schizoaffective Disorder

o periods of time w/ symptoms required for schizophrenia w/ depressive, manic, or mixed episodes --schizophrenia plus bipolar manic disorder or depressive disorder